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Nutrition and hydration in palliative care

Hannah RobertsSpecialist Upper GI Cancer Dietitian

Bradford Teaching Hospitals

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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

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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?

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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?

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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

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Hydration

Good hydration essential for well-being

Adequate fluid provision should not impair appetite

Nourishing fluids

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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

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Risks of nutrition support in palliative care

Aspiration Sepsis Haemorrhage Can prolong death Evoke feelings of fear and despair

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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

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Types of nutrition support

Oral Enteral Parenteral

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Oral nutrition

High energy and high protein diet Food fortification Appetite stimulation

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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

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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!!

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Oral nutrition

Supplements (many different types!)

- high energy and high protein drinks

- high energy “medicine”

- puddings

- powders

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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”

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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

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Enteral nutrition – when to use it

Depends on the individual patient Unable to take nutrition orally Persistent swallowing difficulties

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Parenteral nutrition

Through a vein Requires appropriate access (usually

through a central line) Home parenteral nutrition is rare in

palliative care in England

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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?

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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?”

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Case study 1 – issues raised

Would NG feeding be of benefit to the patient?

Do we have the right to refuse to artificially feed?

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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?

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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

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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

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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

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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