Nutritional Issues in Palliative Care

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Nutritional Issues in Palliative Care
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Malnutrition

• Common in at least 80 of advanced cancer pts
• Especially lung, GI tumors
• Exceptions - breast ca, hematological ca

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CACS Cancer-Anorexia-Cachexia Syndrome

• Profound nutritional depletion

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Cachexia

• Karos bad hexis condition (Greek)
• Complex metabolic syndrome characterized by
  progressive, involuntary weight loss
• General ill health with malnutrition
• Weakness, emaciation

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Implications of Malnutrition

• Poor performance status
• Decreased tolerance to chemo/radiation
• Increased physical and mental fatigue
• Increased rate of infection/complications
  post-op
• Decreased survival
  poor prognostic
  indicator

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CACS Clinical manifestations

• Weight loss
• Weakness
• Chronic nausea - delayed gastric emptying
• Extreme fatigue and weakness asthenia

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CancerTumor Byproducts
CytokinesMetabolic Abnormalities
AnorexiaProtein Loss LipolysisMalnutrition
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Clinical Management

• Ideal- reverse the CACS
• Anorexia-
• Steroids, progestational drugs (Megace),
  cannabinoids

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Clinical management
Chronic nausea - prokinetic agents, useful in
delayed gastric emptying Effect on body image?
Rarely addressed in the literature
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Clinical Managment

• Should pts with CACS have more calories?
• What about TPN?
• What about tube feeding?

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Aggressive nutritional support

• No significant impact on survival
• No significant impact on response to
  antineoplastic therapy
• No significant impact on toxicity of
  antineoplastic therapy
• Minimal effects on overall nutritional status
• May aggravate chronic nausea

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Does TPN feed the tumor?

• Yes, in rats
• Not known in humans

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Risk factors for Dehydration in Terminally Ill

• Decreased oral intake secondary to possible
  dysphagia, nausea, anorexia, decreased LOC
• Fluid loss from possible bleeding, vomiting,
  diarrhea, wound drainage

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Terminal Dehydration

• Decreased circulating blood volume
• Dry skin mucous membranes
• Postural hypotension
• Thickened secretions

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Terminal Dehydration

• Oliguria
• Decreased tissue perfusion cerebral hypoxia
• Electrolyte, acid/base changes
• Azotemia

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Terminal Dehydration

• Contrast with dehydration of otherwise healthy
  person with acute illness
• Headache
• Fever
• Abdominal cramps
• Nausea vomiting
• Dry mouth

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Arguments for Rehydration

• Recognized cause of confusion and agitation
• Renal failure results in greater accumulation of
  metabolites
• Myoclonus, confusion, agitation
• Dehydration increases risk of bed sores
• Dehydration makes constipation worse
• Ethical considerations re minimum standard of
  care

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Arguments against Rehydration

• Comatose pts unlikely to experience discomfort
  from thirst
• Fluid may prolong the dying process
• Less urine output less need for bedpan,
  urinal, etc

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Arguments against Rehydration

• Less GI fluid and less vomiting
• Less pulmonary congestion, coughing
• Natural anaesthesia - decreased LOC
• Parenteral hydration limits mobility/comfort
• Thirst readily controlled with sips and mouth
  care

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Hypodermoclysis

• Easy to initiate, given s/c
• Can be stopped and started without concern for
  clot formation
• Hospitalization can be avoided or shortened
• S/C sites last for several days