Unit 8:Unit 8:Nutritional CounselingNutritional CounselingStacey Day, MS, RD

Kaplan University

Palliative CarePalliative CareMake comfortable

by treating a person’s symptoms from an illness.

Improve quality of person’s illness

Support patient and family before and after treatment.

Hospice CareHospice CareBelief that each

person has a right to diet pain-free and with dignity

Loved ones will receive the necessary support.

Focus: Caring not curing.

Typically less than 6 months to live.

What are the five stages of death that both the patients and caregivers go through when told the prognosis of imminent death?

Stages of Dying: DenialStages of Dying: DenialShockDisbeliefConsumes you

day and night

“The test must be wrong”

“I want another opinion”

Stages of Dying: AngerStages of Dying: AngerRage and hostility

to both diagnosis and family, caregivers, and physicians.

Loss of control of life

Feelings of helpless and upset

Anger can be debilitating or empowering.

“Why didn’t I see those signs sooner?”

“The doctor missed this in my physical last year.”

Stages of Dying: Stages of Dying: BargainingBargainingWillingness to

compromise in hope for more time or change in prognosis.

May agree to chemo if it will buy you another 6-9 good months

“Just wait until daughter gets married”

“Even possibly become miraculously cured.”

Stages of Dying: Stages of Dying: DepressionDepressionMourn for

yourselfMourn for your

loved ones’ pain and grief.

Mourn past and future losses.

Symptoms cannot be ignored and death is realized as inevitable

Stages of Dying: Stages of Dying: AcceptanceAcceptanceWorked through

feelings that death brings you.

Calmness and at ease, peace

Final stage with understanding that there is nothing else curative that can be done.

Questions??Questions??

MalnutritionMalnutrition50% Hospitalized

Patients40% Long-term

Patients

MalnutritionMalnutritionRecurrent

infectionsPressure ulcers

that fail to healColonization of

bacteria due to low immune status

EdemaAnemiaFatigue

MalnutritionMalnutritionPoor appetitePoor ability to

swallowUpset stomachAltered food taste

due to meds and disease processes◦ Sweet◦ Sour◦ Salty◦ Metallic

Nutrient DeficienciesNutrient DeficienciesWhich nutrients impact wound

healing in those with surgical wounds or decubiti?

Nutrient DeficienciesNutrient DeficienciesVitamin AVitamin CVitamin EVitamin DZinc

Name that nutrient?Name that nutrient?This vitamin

deficiency accompanies hypocalcemia and hypophosphotemia.

Subtle complaints of muscle weakness, pain, or a more severe finding, neuromuscular irritability.

Vitamin DVitamin DThis vitamin

deficiency accompanies hypocalcemia and hypophosphotemia.

Subtle complaints of muscle weakness, pain, or a more severe finding, neuromuscular irritability.

Name that NutrientName that NutrientAids in immune

functionAids in synthesis

of important cell components

Aids in formation of skin

Vitamin CVitamin CAids in immune

functionAids in synthesis

of important cell components

Aids in formation of skin

Name that NutrientName that NutrientEssential in the

production of skin cells

Lack of nutrient can result in vulnerability to infection

Vitamin AVitamin AEssential in the

production of skin cells

Lack of nutrient can result in vulnerability to infection

Name that NutrientName that NutrientProtects the skin

from oxidation by free radicals

Anti-inflammatory

Supplements scar formation

Vitamin EVitamin EProtects the skin

from oxidation by free radicals

Anti-inflammatory

Supplements scar formation

Name that NutrientName that NutrientImmune enhancerComponent of 200

or more enzymesCells vulnerable to

this nutrient deficiency◦ Skin◦ Blood cells◦ Cells lining GI tract

ZincZincImmune enhancerComponent of 200

or more enzymesCells vulnerable to

this nutrient deficiency◦ Skin◦ Blood cells◦ Cells lining GI tract

Questions??Questions??

4 Nutrition Phases of 4 Nutrition Phases of DyingDyingEarly Dying

PhasePreHospice

PhasePreactive PhaseActive Phase

Nutrition Phases of Dying:Nutrition Phases of Dying:Early Dying PhaseEarly Dying PhaseStill choose

aggressive medical care both tradition and non-traditional.

Nutritional status may be highly affected in this stage

Progressive disease state

Aggressive therapies

Nutrition Phases of Dying:Nutrition Phases of Dying:Early Dying PhaseEarly Dying PhaseFatigueConstipationPoor wound

healingNeurological

problems

Evaluate weight loss

Food IntakeAvailable lab

values

Nutrition Phases of Dying: Nutrition Phases of Dying: Early Dying PhaseEarly Dying Phase Pain

◦ Encourage meds to decrease pain

◦ Pt. refuses to eat or only eats comfort food

◦ Nutritional status may decrease

Constipation◦ Meds may cause this◦ Disease or treatment

of disease◦ OTC: laxative◦ Natural remedies

Diarrhea◦ Dehydration◦ Poor nutrient

absorptions◦ Replace fluids: 1

cup per BM◦ Sports drinks,

broths, other K-Na containing fluids

◦ Anti-diarrheal meds

Nutrition Phases of Dying: Nutrition Phases of Dying: Early Dying PhaseEarly Dying Phase Nausea/Vomiting

◦ Small amounts of dry foods

◦ Bland foods◦ Frequent small meals◦ Snacks◦ Herbal teas◦ Cold better than hot◦ Plastic instead of

silverware to eliminate metallic taste

◦ Tart is easier than sweet (lemonade, citrus flavors)

Chewing/Swallowing◦ Brush regularly aids

in dry mouth◦ Hard candies and

frozen grapes help◦ Mouth sores: Soft or

pureed foods. Foods at room temp.

◦ Dysphasia Coughing or choking

while eating/drinking Danger: aspiration of

food or fluids into lungs

Nutrition Phases of Dying: Nutrition Phases of Dying: PreHospice PhasePreHospice PhaseDisease StrongerPerson weakerMuscle wasting,

malnutrition, swallowing, and wanting to eat is problematic

Artificial nutrition and hydration are considered.

Is ANH Appropriate for Is ANH Appropriate for Patients at the End of Life?Patients at the End of Life?Needs to be decided as a medical

therapySpecialized trained professionals

needed to place the equipment and monitor closely

Provides adequate nutrition and hydration to make the patient comfortable towards the end.

Ask Questions with regards Ask Questions with regards to goals of patientto goals of patientANH may be appropriate if benefits

outweigh risks.Strong emotions become

unavoidable.Your duty is to talk it through with

them, but they need to an informed decision

Parenteral nutrition is rarely usedEnteral nutrition is at the forefront

of discussions

Delivery Methods of AN:Delivery Methods of AN:Nasogastric (NG) TubeNasogastric (NG) Tube

Delivery Methods of AN:Delivery Methods of AN:Gastrostomy (PEG tube)Gastrostomy (PEG tube)

Delivery Methods of AN:Delivery Methods of AN:Jejunostomy (J tube)Jejunostomy (J tube)

Complications and Complications and Disadvantages of ANDisadvantages of ANObstruction of the bowelRisk of aspiration pneumoniaPhysical symptoms with artificial

nutrition are often a result of the fluid that is provided within the formula and water used during flushing of the tubes

Infection at PEB or IV siteNasal necrosis or acute hemorrhage

Complications and Complications and Disadvantages of ANDisadvantages of ANLoss of patient autonomy as they are no

longer in charge of nutritionNGT are uncomfortable and could end up

with sedation meds and/or restraints – may be true for PEG as well.

Financial costs are higherBloating, diarrhea, n/v are not preventedBlocked and leaking tubes require

multiple replacementsSometimes the family will not allow the

tube to be removed in the future.

Nutrition Phases of Dying:Nutrition Phases of Dying:Preactive PhasePreactive PhaseAverage 2 weeksLower blood

pressureLong pauses in

breathing (apnea)

Decrease in food intake and liquids

Patient may refuse both.

Nutrition Phases of Dying:Nutrition Phases of Dying:Active PhaseActive PhaseMay only last 3

days.Patient is unable

or unwilling to swallow and take fluids or food.

Questions??Questions??

Case Study #1Case Study #1 An 80 year old male, F. H., is present with advanced stage

Alzheimer’s because he is not eating that well. His son is present and reports that his father is currently living with him and his wife because he does not have the heart to put him in a nursing home and knows his life is almost over. He reports that his father was eating very well 1 year ago, but then all of a sudden he stopped eating. He reports they have home health nurses come in when his wife and he are at work and during that time the nurses tell them, they have tried feeding him, but he will only take a few bites of food and will sometimes start choking on it. The son reports they have tried giving him Ensure, but his father really does not like it no matter if they add ice cream to it or not. His son is very concerned and knows his father does not have that much longer to live, but also wants to make sure his father eats.

Height: 5’8” Weight: 150 lbs Weight history: 180 lbs (1 year ago)

Is his weight loss severe? What is his current BMI? What do you do in this situation? What type of nutrition information do you provide to them? Do you establish goals or a follow up appointment with them?

Case Study #2Case Study #2 A 60 year old male, M. D., is present with liver cirrhosis due to

a 30 year history of alcohol abuse and does not know what he can do to stop the fluid from accumulating. He reports the doctor told him he probably has less than 1 year to live and should have stopped drinking a long time ago, but only gave it up about 2 years ago. He reports his doctor told him he is malnourished, but keeps gaining fluid and does not know why and how he can be malnourished when he eats 2 good meals. He reports he goes out to eat at least 2 times per week, drinks iced tea with sugar throughout the day and still smokes.

Height: 6’0” Weight: 200 pounds

What is his BMI? And do you believe his weight to be reliable? What other information would you obtain from him? What type of nutrition information would you provide to him? How much fluid would you tell him to drink? What goals would you establish from him and would you follow

up with him?