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The Safest care in the North of England
Nutrition and hydration in palliative care
Hannah RobertsSpecialist Upper GI Cancer Dietitian
Bradford Teaching Hospitals
The Safest care in the North of England
Aims Know the different types of nutrition
support available Be able to choose and justify the most
appropriate method of nutrition support for palliative patients
Consider the ethical and moral arguments for artificial nutrition
Understand the role of the dietitian in palliative care
The Safest care in the North of England
Quick Quiz! Name 2 benefits of nutrition support in
palliative care Name 2 risks of nutrition support in palliative
care Give an example of food fortification Give an example of a supplement drink that
needs to be prescribed What is enteral nutrition? Give an example What is parenteral nutrition?
The Safest care in the North of England
Ethics and legality
Hydration is basic care Spoon feeding is basic care Artificial nutrition is not basic care
and classed as a medical intervention Key question:
Do the benefits outweigh the risks?
The Safest care in the North of England
Once started can you stop? Legal equivalence of withdrawal and
withholding Can feel more comfortable not to start
than to start and then discontinue Don’t deny patient the right of a trial
of therapy Can trial with agreed objectives and
time for review
The Safest care in the North of England
Hydration
Good hydration essential for well-being
Adequate fluid provision should not impair appetite
Nourishing fluids
The Safest care in the North of England
Benefits of nutrition support in palliative care
Increase energy levels Resistance to infection Minimise muscle wasting and pressure
sores Allows patient to retain some control over
their illness Helps to maintain a sense of normality Can improve quality of life and sense of
well being
The Safest care in the North of England
Risks of nutrition support in palliative care
Aspiration Sepsis Haemorrhage Can prolong death Evoke feelings of fear and despair
The Safest care in the North of England
When to use nutrition support Disease related malnutrition Weight loss Reduced appetite and early satiety Swallowing difficultiesAlso depends on stage of diseaseCurative phase – always appropriatePalliative phase – usually appropriateTerminal phase – rarely appropriate
The Safest care in the North of England
Types of nutrition support
Oral Enteral Parenteral
The Safest care in the North of England
Oral nutrition
High energy and high protein diet Food fortification Appetite stimulation
The Safest care in the North of England
Food FortificationBreakfastBreakfast PorridgePorridge Toast + butterToast + butter Cup of teaCup of teaLunchLunch Cup-a-soupCup-a-soup BananaBananaEvening mealEvening meal Poached cod and jacket potatoPoached cod and jacket potato YoghurtYoghurtExtrasExtras Tea between mealsTea between meals Horlicks at supperHorlicks at supper
Total: 980 calories and 48g proteinTotal: 980 calories and 48g protein
The Safest care in the North of England
What difference can food fortification make?
BreakfastBreakfast Porridge….. Porridge….. Swap to whole milk and add golden syrupSwap to whole milk and add golden syrup Toast + butter….. Toast + butter….. Add jamAdd jam Cup of tea….. Cup of tea….. Make with whole milkMake with whole milkLunchLunch Soup….. Soup….. Swap to a creamy soup Swap to a creamy soup Add bread and butterAdd bread and butter Banana….. Banana….. Add custardAdd custardEvening mealEvening meal Poached cod….. Poached cod….. Add a cheese sauceAdd a cheese sauce Jacket potato….. Jacket potato….. Add butterAdd butter Yoghurt….. Yoghurt….. Swap to a trifleSwap to a trifleExtrasExtras Tea between meals….. Tea between meals….. Make with whole milk Make with whole milk Horlicks at supper….. Horlicks at supper….. Make with whole milkMake with whole milk Add 2 biscuits and a slice of cakeAdd 2 biscuits and a slice of cake
Total: 2070 calories and 75g proteinThat’s an extra 1090 calories and 27g protein!!
The Safest care in the North of England
Oral nutrition
Supplements (many different types!)
- high energy and high protein drinks
- high energy “medicine”
- puddings
- powders
The Safest care in the North of England
Oral nutrition – when to use it
If a patient can eat let them eat! Majority of palliative care patients Encourage higher calorie options (if
liked) Use of supplements if a patient can’t
eat “enough”
The Safest care in the North of England
Enteral nutrition “using a tube” Naso-gastric (NG) Naso-jejunal (NJ) Gastrostomy e.g. PEG, RIG Jejunostomy Artificial feed (as recommended by the
dietitian) is put down the tube via a pump or syringe
Medication and fluids can be put down too Can be sole source of nutrition or to
supplement oral intake
The Safest care in the North of England
Enteral nutrition – when to use it
Depends on the individual patient Unable to take nutrition orally Persistent swallowing difficulties
The Safest care in the North of England
Parenteral nutrition
Through a vein Requires appropriate access (usually
through a central line) Home parenteral nutrition is rare in
palliative care in England
The Safest care in the North of England
Parenteral nutrition – when to use it
Should it be used at all in palliative care?
Non-functioning GI tract e.g. intestinal failure
Do the risks outweigh the benefits?
The Safest care in the North of England
Case study 1 67 year old male with laryngeal cancer April 04 - total laryngectomy Oct 06 - dysphagia CT scan showed bulky lymph node recurrence Managing soft diet but not meeting nutritional requirements NG tube inserted. Discharged home with NG feed. Completed palliative chemoradiotherapy Feb 07 - weight gain and improvement in oral intake. NG
tube removed July 07 - represented with lower oesophageal dysphagia on
a liquidised diet and sip feeds. Oesophageal stent inserted and oral intake improved
Dec 07 - general deterioration, weight loss, minimal oral intake, poor prognosis
Patient and family – “could he have another NG tube please?”
The Safest care in the North of England
Case study 1 – issues raised
Would NG feeding be of benefit to the patient?
Do we have the right to refuse to artificially feed?
The Safest care in the North of England
Case study 2 60 year old female May 06 - Diagnosed with locally advanced
pancreatic cancer For palliative chemotherapy 12% weight loss in 6 weeks Early satiety and poor appetite Steattorhoea Following a low fat diet Blood sugar readings 20+ mmol/l
What is the most appropriate method of nutrition support for this patient?
The Safest care in the North of England
Case study 2 – issues raised Review of diabetes medication Commence pancreatic enzymes Not a low fat diet! Food first High energy and high protein diet Food fortification Nutritional supplements Avoid unnecessary consumption of simple
sugars but not at the cost of energy intake
The Safest care in the North of England
The last few days
Food and fluids for pleasure and comfort not for survival
Consider patient’s wishes, anxiety and physical symptoms
Nutrition support not usually appropriate
Artificial hydration is controversial
The Safest care in the North of England
The role of the dietitian in palliative careAdvice on:
poor appetite sore or dry mouth taste changes early satiety GI symptoms
Assessing nutritional needs and problems Establishing which nutritional support
measures are appropriate Use of appropriate supplements Enteral and parenteral nutrition support Advice and guidance to carers Training of staff and catering
Bradford dietitians are based at St Luke’s Hospital. Telephone number: 01274 365108
The Safest care in the North of England
Conclusions Range of nutritional support options
available to use in palliative care Deciding when to use nutrition support
can be difficult Decision should be made as part of a
multi-professional team (including the patient!)
Discussions should happen earlier rather than later
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