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The EPEC™-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
Education in Palliative and End-of-life Care - Oncology
The
Projec
t
EPEC-OTM
Overall message
Withholding or withdrawing life-sustaining therapies
is sometimes warranted, is ethical and legal in many
circumstances.
Examples of life-sustaining
therapies
Resuscitation
Intubation/mechanical
ventillation
Blood transfusions
Dialysis
AICD
Antibiotics
Artificial
hydration/nutrition
Hospitalization/ICU
admissions
Surgery
Diagnostic tests
Let’s talk about food
Enteral Nutrition
NG, PEG, Jtube
Head & neck cancer,
Neurologic injury
Temporary loss of ability
to eat.
Enteral Nutrition & Survival
No effect on:
Aspiration risk
Pneumonia risk
Symptoms.
Associated with increased mortality in patients with
dementia, etc.
Parenteral nutrition
Venous access
Beneficial with: long-term gi toxicity, short gut
syndrome, ovarian carcinomatosis.
Not beneficial in: long-term feeding for
cachexia/anorexia.
Effects of nutrition on survival
& response rates
Odds ratio
Control 1.00
Survival0.81
p < 0.05
Tumor
response0.68
Parenteral hydration
IV or SQ
Does not relieve dry
mouth
Common Concerns
Legally required to do everything?
Is withholding or withdrawing care euthanasia?
Are you (or the family) killing the patient by
withholding or withdrawing nutrition, fluid, or life-
sustaining treatment?
Steps to discuss withholding/withdrawing
artificial nutrition/hydration
S – set-up, background
P – Preparation
I – Inquiry: what are the goals? What is the understanding? What
cultural beliefs?
K – Knowledge: listen and share. Address misperceptions. (Not
alleviate: dry mouth, decrease intake, fatigue/energy, starvation,
urine output. Side effects: fluid overload, breathlessness,
nausea/vomiting.)
E – Emotions: wait. Acknowledge. (starvation, giving up,
suffering, “not doing something”)
S – Summarize/strategize
Cases
“We want to do what’s best, and
what she wanted us to do…”
CS is an 82 yo woman found unresponsive at home.
Found to have large hemorrhagic stroke MCA, with
only brainstem function remaining. PMH: HTN, high
cholesterol.
Exam: Respirations shallow, rapid. HR fast.
Unresponsive.
Brought “comfort one” form from refrigerator.
Niece is HCP. Agrees DNR/DNI no ICU. What is comfort care?
Pt hasn’t eating in 3 days: doesn’t she need IVFluids, blood
tests, oxygen tests?
“I don’t want her to starve”
89 yo patient with advanced Alzheimer’s dementia
(speaks only a few intelligible words, dependent on
all ADLs) admitted with dyspnea, cough, mental
status change found to have aspiration pneumonia.
Found to have aspiration pneumonia. Failed swallow
evaluation.
Daughter/son knows patient doesn’t want pt to
starve, but is concerned that pt can’t swallow.
Additionally, nursing home might require
feeding tube for readmission.
Thank you