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Nutritional Issues in Palliative Care

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There seems to be some survival benefit . * My emphasis * * Ganzini cites 3 well-designed studies showing . And one could be forgiven for suspecting that ... – PowerPoint PPT presentation

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Title: Nutritional Issues in Palliative Care


1
(No Transcript)
2
"Everything Stops for Tea"
  • Nutrition, Eating, and Palliative Care

Ted St. Godard MA MD
3
  • Let food be your medicine and let medicine be
    your food.
  • Hippocrates
  • Sex is good, but not as good as fresh, sweet
    corn. 
  • Garrison Keillor

4
Objectives
  • Psycho-social aspects of eating and not eating
  • starving, wasting, some patients
  • Approach to patients and families
  • Nutrition challenges in the gravely ill
  • Cachexia versus Starvation (? Decreased PO
    starvation)
  • Role for Artificial Nutrition
  • Yes, no, maybe so?
  • Palliative Perspective

5
I. Psychosocial issues
Nothing would be more tiresome than eating and
drinking if they were not a pleasure as well as
a necessity.  Voltaire
6
I. Psychosocial issues
  • Meals/eating highly loaded
  • celebrations, milestones, happy times, sad times,
    memories
  • Many or most patients with terminal illness
    ultimately are unable to eat enough to avoid
    weight loss and maintain activity levels

7
I. Psychosocial issues
  • Patients
  • Body image? Sexuality?
  • Embarrassment, shame, guilt, frustration
  • Weaker and weaker, smaller and smaller
  • Im wasting away

8
I. Psychosocial issues
  • Families
  • Frustration, anger
  • LO weaker, smaller, frailer, but wont eat
  • Try harder, vicious circle
  • Conflict
  • We cant just let her/him starve

9
I. Psychosocial issues
  • Starvation
  • We live in a world where this ought not to happen
  • Unconscionable
  • Wasting
  • Inefficient, shameful, immoral?

10
I. Psychosocial issues
  • Nutrition is a basic animal need
  • Is feeding a fundamental component of care? A
    right?

11
I. Psychosocial issues
  • 38 male, metastatic esophageal Ca.
  • Presented with pneumo-mediastinum
  • PEG
  • Cachectic, ate (copiously) for months
  • 53 female, metastatic ovarian Ca., bowel
    obstruction
  • Obese, eating (copiously) around NG
  • Increasing emesis How will we feed her now?

12
I. Psychosocial issues
  • 73 male, metastatic hepato-cellular Ca.,
  • Frail, bedbound, cachectic, icteric
  • Doctor, he no eat. Make him eat
  • 53 female, metastatic breast Ca., bowel
    obstruction (multiple omental mets, abd/pelvic
    adenopathy)
  • Looks well, ambulating
  • So now I just starve to death?

13
II. Approach to patients/families
14
II. Approach to patients/families
  • Goals of Care

(Maintain quality of life avoid prolongation of
dying)
15
II. Approach to patients/families
  • WHO definition
  • Palliative care is an approach that improves the
    quality of life of patients and their families
    facing the problem associated with
    life-threatening illness, through the prevention
    and relief of suffering by means of early
    identification and impeccable assessment and
    treatment of pain and other problems, physical,
    psychosocial and spiritual.

16
II. Approach to patients/families
  • WHO definition
  • improves quality of life of patients and their
    families
  • prevention and relief of suffering
  • ..early identification, assessment and
    treatment of
  • . problems, physical, psychosocial and
    spiritual.

17
II. Approach to patients/families
Palliative Care
Death
Active Treatment
18
II. Approach to patients/families
Palliative Care
Death
Active Treatment
19
II. Approach to patients/families
Cure, restore function, prolong life,
provide comfort
20
II. Approach to patients/families
Comfort always
21
III. Nutrition Challenges in PC
  • Failure to achieve balance
  • Decreased PO intake
  • Anorexia, xerostomia, altered taste/smell,
    odyno/dysphagia
  • Decreased absorption
  • Altered energy utilization

22
III. Nutrition Challenges in PC
  • Inadequate ingestion
  • Developed countries medical reasons
  • Worldwide lack of food

23
1. Decreased PO intake
  • Anorexia (loss of appetite)
  • Multi-factorial
  • Cytokines central (hypothalamic) and
    peripheral (via vagus nerve) influences
  • Huge frustration for families, source of much
    tension

24
A
B
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Anorexigenic Neuropeptide
Orexigenic Neuropeptide
Neurotensin
MCH
Neurotensin
MCH
_
_
CNS Cytokinase
Melanocortin
AGRP
Melanocortin
AGRP
CNS Cytokinase
CNTF
_
IL-1
IL-1 IL-6 TNF-? INF-?

_
_
CRF
NPY
CRF
NPY
Tryptophan

_

Seratonin
Food Intake Energy Expenditure
_
_

ACTH
Food Intake Energy Expenditure
Blood Brain Barrier
Blood Brain Barrier
Glucocorticoids


_

IL-6


Glucogon
Glucogon
Cytokinase
CNTF
IL-1
CCK
Leptin
CCK
Leptin




25
Anorexia (loss of appetite)
  • Approach
  • Symptom control (nausea, pain)
  • Meal selection, timing, portion/presentation
  • Avoid/reduce conflict (eat, drink, be merry)
    eat what, where, when, as much/little as you
    want

26
4. Pharmacology in anorexia Tx
  • Progestational agents Megestrol
  • Corticosteroids Dexamethasone

27
4. Pharmacology in anorexia Tx
  • ?Metoclopromide
  • ?Cannabinoids
  • ?Melatonin (decrease TNF)
  • ?NSAIDS (decrease inflammatory mediators)

28
4. Pharmacology in anorexia Tx
  • Appetite stimulants may increase intake, body
    weight, and quality of life, but they do not
    affect prognosis in the terminally ill

Dy, M. Enteral and Parenteral Nutrition in
Terminally Ill Cancer Patients a Review of the
Literature. American Journal of Hospice and
Palliative Medicine. 2006 23 (5) 369-377
29
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30
2. Decreased absorption
  • Nausea
  • Emesis
  • Diarrhea
  • Surgical/anatomical changes
  • 3. Altered energy metabolism

31
IV. Cachexia versus Starvation
  • Starvation pure protein/energy deficiency
    (under-nutrition)
  • Cachexia cytokine-induced wasting of protein and
    energy stores, caused by effects of disease
  • Malignancy, COPD, ESRD, CHF, AIDS, RA
  • Remarkably resistant to hyper-caloric feeding

Thomas, D. Distinguishing Starvation from
Cachexia. Clinics in Geriatric Medicine. 2002
18 883-891
32
IV. Cachexia versus Starvation
  • Biochemical markers represent nutritional status
    or illness severity?
  • Acute-phase cytokine response
  • Strong inverse correlation between IL-2R and
    albumin, pre-albumin, cholesterol, Hgb
  • Common pathway to reduction in albumin, etc. may
    be cytokine induction, rather than absence of
    nutrients

Thomas, D. Distinguishing Starvation from
Cachexia. Clinics in Geriatric Medicine. 2002
18 883-891
33
IV. Cachexia versus Starvation
Thomas, D. Distinguishing Starvation from
Cachexia. Clinics in Geriatric Medicine. 2002
18 883-891
34
V. Role of Artificial Nutrition
  • Ethical Principles
  • Autonomy
  • Beneficence
  • Non-maleficence
  • Informed consent

Beauchamp and Childress. Principles of Biomedical
Ethics. New York Oxford University Press. 1994
(4th Ed.)
35
V. Role of Artificial Nutrition
  • Informed consent. Patient/surrogate
  • Is able to communicate consistent preference
  • Understands risks, benefits, and alternatives
  • Appreciates the information
  • Uses rational thinking to arrive at decision

Beauchamp and Childress. Principles of Biomedical
Ethics. New York Oxford University Press. 1994
(4th Ed.)
36
V. Role of Artificial Nutrition
  • Nutrition is a basic animal need
  • Is feeding a fundamental component of care? A
    right?

37
V. Role of Artificial Nutrition
  • Artificial, specialized nutritional support is no
    different from any other life sustaining medical
    therapy that supports bodily function, such as
    antibiotics, oxygen therapy, or dialysis.
  • Not offering it is ethically acceptable if
    benefits do not outweigh the risks for a
    particular individual.

McClave , S., Ritchie, C. The Role of
Endoscopically Placed Feeding or Decompression
Tubes. Gasteroenterology Clinics of North
America. 2006 35 83 - 100
38
V. Role of Artificial Nutrition
  • There is no ethical or legal difference between
    withholding a feeding tube versus placing the
    feeding tube and then later removing it

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
39
V. Role of Artificial Nutrition
  • Several Groups of Potential Beneficiaries
  • Malignant disease
  • Acute CVA
  • Dementia
  • Neurodegenerative diseases

40
V. Role of Artificial Nutrition
  • Two Potential Benefits
  • Prolong life
  • Palliate improve comfort, enhance quality of
    life (for patients and their care-givers/loved
    ones)

41
V. Role of Artificial Nutrition
  • Patients with Malignancies
  • Despite increased nutrient delivery, trials show
    disappointing results in improving clinical
    outcome
  • Improvements in biochemical markers
    inconsistently correlate with objective clinical
    benefits

Thomas, D. Distinguishing Starvation from
Cachexia. Clinics in Geriatric Medicine. 2002
18 883-891
42
V. Role of Artificial Nutrition
  • Patients with Malignancies
  • ?survival benefit if PEG in early head and neck
    cancers (tolerate treatments better)

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
43
V. Role of Artificial Nutrition
  • Patients with Malignancies
  • Little evidence was found for benefits from
    enteral or parenteral nutrition in terminally ill
    cancer patients, other than for those with
    mechanical gastrointestinal tract obstruction

Dy, M. Enteral and Parenteral Nutrition in
Terminally Ill Cancer Patients a Review of the
Literature. American Journal of Hospice and
Palliative Medicine. 2006 23 (5) 369-377
44
V. Role of Artificial Nutrition
  • Hunger
  • Often not noted
  • Ameliorated usually with small amounts food/drink

Dy, M. Enteral and Parenteral Nutrition in
Terminally Ill Cancer Patients a Review of the
Literature. American Journal of Hospice and
Palliative Medicine. 2006 23 (5) 369-377
45
V. Role of Artificial Nutrition
  • Acute CVA with Dysphagia
  • ? Survival
  • ? Morbidity

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
46
V. Role of Artificial Nutrition
  • Acute CVA with Dysphagia
  • RCT compared tube feeds within 7 days of
    admission versus no tube feeding for more than 7
    days
  • Early tube feeding associated with NS reduction
    in risk of death (ARR 5.8 )
  • ? Survival ? offset by 4.7 excess of survivors
    who had poorer outcomes

Dennis, Lewis, Warlow, C. Effect of Timing and
Method of Enteral Tube Feeding for Dysphagic
Stroke Patients. Lancet. 2005 26 (365) 764 -
772
47
V. Role of Artificial Nutrition
  • Dementia
  • 34 pts. with dementia or cognitive impairment
    have PEGs
  • Prevent aspiration, heal/preven skin ulcers,
    prolong life
  • Evidence equivocal at best on all counts

McClave , S., Ritchie, C. The Role of
Endoscopically Placed Feeding or Decompression
Tubes. Gasteroenterology Clinics of North
America. 2006 35 83 - 100
48
V. Role of Artificial Nutrition
  • Dementia
  • Patients with dementia who are so disabled as to
    stop eating have poor prognosis even with PEG
  • PEG in demented patients huge risk factor for
    restraints

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
49
V. Role of Artificial Nutrition
  • Neurodegenerative disease
  • ALS
  • Cognition usually spared
  • 10 20 5-year survival without artificial
    ventilation and nutrition
  • With support, lifespan can be extended
    indefinitely

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
50
V. Role of Artificial Nutrition
  • Neurodegenerative disease
  • PEG in ALS
  • Improves nutrition
  • Makes eating easier (lessens fatigue)
  • Decreases time spent feeding
  • Allays fears of choking
  • ? Improved QOL

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
51
V. Role of Artificial Nutrition
  • Neurodegenerative disease
  • PEG in ALS
  • Mortality benefit?
  • Survival increased only in patients where PEG
    inserted early
  • FVC lt 50 predicted increases risk mortality

Ganzini, L. Artificial Nutrition and Hydration
at the End of Life Ethics and Evidence.
Palliative and Supportive Care. 2006 4 135 - 143
52
V. Role of Artificial Nutrition
  • Several Groups of Potential Beneficiaries
  • Malignant disease
  • Acute CVA
  • Dementia
  • Neurodegenerative diseases
  • Two Potential Benefits
  • Prolong life
  • Palliate improve comfort, enhance quality of
    life (for patients and their care-givers/loved
    ones)

53
VI. Recap
  • Issues surrounding eating and nutrition come to
    play a very significant role in the lives of
    people with most end stage illnesses
  • Often more difficult for families than patients
  • Potential source of much conflict

54
VI. Recap
  • Decreased PO intake, and altered ability to
    metabolize nutrients effectively is etiologically
    complex
  • Depending on goals of care, there sometimes is a
    role for medication and/or artificial nutrition
  • Treatment must always and everywhere take into
    considerations of goals of care

55
(No Transcript)
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