NUTRITION AND HYDRATION AT END OF LIFE

1
NUTRITION AND HYDRATION AT END OF LIFE

• Lisa Shives MD
• Horizon Hospice
• June 28, 2004

2
REASONS FOR NUTRITIONAL DECLINE

• Cancer Anorexia-Cachexia Syndrome
• Dysphagia
• A. Dementia
• B. Stroke
• C. Coma or PVS
• D. OP or Esophageal Malignancy
• FTT

3
DONT FORGET UNCONTROLLED, DISTRACTING SYMPTOMS

• PAIN
• SOB
• NAUSEA/VOMITING
• DIARRHEA/CONSTIPATION

4
ANOREXIA

• Nonpharmacologic Treatments
• 1. Treat OP discomfort from stomatitis, e.g.
  candidiasis, or mouth ulcers
• 2. Encourage modification of eating habits
• A. Smaller, more frequent meals
• B. Lift dietary restrictions, e.g. low salt,
• low fat, ADA
• 3. Chew and Spit

5
ANOREXIA

• Pharmacologic Interventions
• 1. Steroids
• --Maximum appetite stimulation achieved within 4
  weeks
• --Side effects
• 2. Megestrol Acetate (Megace)
• --When used at end of life, if benefits are not
  seen after 1 week, they are unlikely to occur
  later.
• --Some authorities recommend starting it earlier

6
ANOREXIA

• 3. Metoclopramide (Reglan)
• --Increases gastric emptying
• --Also treats nausea and dyspepsia
• 4. THC
• --Few trials which have tended to be small and
  focused on chemo pts
• --Mixed results
• --Side effects

7
NPO

• Why do we recommend nothing by mouth?
• Aspiration risk--determined by swallowing study
  in the hospital. In the home, ask about choking,
  coughing or pocketing food
• Aspiration is Not a good death
• Is it ever acceptable to recommend eating when a
  pt has known aspiration risk?

8
ARTIFICIAL/MEDICAL NUTRITION VS EATING

• A FUNDAMENTAL DISTINCTION

• Always keep in mind the importance of this
  distinction
• Help families and other staff members understand
  this

9
METHODS OF DELIVERING MEDICAL NUTRITION

• TPN TOTAL PARENTERAL NUTRITION
• RISKS Infection, metabolic/lipid abnormalites,
  liver dysfunction
• Only used short term usually in acutely ill pts
  after all enteral options have been explored.

10
METHODS OF DELIVERING MEDICAL NUTRITION

• ENTERAL Via the GI tract
• NGT
• PEG Percutaneous Endoscopic Gastrostomy
• Preferred method if the gut works, use it!
• Risks infection, trauma of self removal, and
  most importantly, the risk of aspiration is NOT
  eliminated

11
WITHHOLDING/WITHDRAWING NUTRITION AND HYDRATION

• Conceptual Foundations of the Discussion
• Commonly-evoked dichotomies
• 1. Withholding vs Withdrawing
• -Is there a difference?
• -Should we make a distinction?
• -Different perspectives
• Ethicists and Courts
• Families
• Physicians

12
DICHOTOMIESBOTH FALSE AND TRUE

• 2. Ordinary vs Extraordinary
• -Formulated by RCC in 1595
• -Permits conflicting interpretations
• 3. Basic vs Heroic Care
• -Similar problem of interpretation
• 4. Killing (or Active Euthanasia) vs a
• Letting Die (or Passive Euthanasia)
• 5. Medical Treatment vs Caretaking

13

• Are Nutrition and Hydration Medical Treatments?
• If so, are they different from other medical
  treatments?
• Ethics
• Law
• Emotions
• Social Mores
• Ethnic/cultural differences
• Should we make a distinction between nutrition
  and hydration?

14
WHO DECIDES WHETHER TO WITHHOLD OR WITHDRAW?

• Principle of Patient Autonomy THE Guiding
  Principle in Biomedical Ethics today
• What happens when patients cannot exercise their
  right to autonomy, that is who decides when
  patients do not have decision-making capacity?

15
WHO DECIDES WHEN PATIENTS CANT

• Living Wills
• POA Power of Attorney for Healthcare
• Illinois Healthcare Surrogate Act
• Principles of Beneficence and Nonmaleficence
  Physician responsibility to act in the best
  interest of patients and, when it is not in their
  best interest to prolong their suffering,
  physicians play an important role in helping to
  relieve the burden on families of making the
  difficult decision to forgo medical treatment.

16
WHAT DOES THE PATIENT EXPERIENCE?

• Notes from Underground
• -Many anecdotes, self reportage, studies
• -This is not a mystery we are not guessing
• we know what it is like to starve.
• Decreased desire for food at end of life
• Importance of sips/chips/oral swabs/good oral
  hygiene

17
WHAT DOES THE PATIENT EXPERIENCE?

• Starvation vs Semi-starvation
• --Ugly terms, but families will use the term
  starvation, so be prepared.
• --2 Things to Stress
• 1. We know that semi-starvation is much more
  uncomfortable.
• 2. We believe that we are allowing
• patients to have a peaceful death due to their
• underlying terminal disease, NOT that we are
• letting them starve to death.

18
WHAT DOES THE PATIENT EXPERIENCE?

• Ketonemia and Endogenous Opioids
• Euphoria
• Decrease in pain
• Improvement in secretions, edema, SOB
• Freedom from the pain and inconvenience of IV
• All the above benefits will be negated if you
  continue IVF, especially with glucose added

19
COMFORT MEASURES ONLY

• Simplify drug regimen
• -Stop all meds whose purpose is not pain or
  symptom control
• Hospitalized Patients Dont forget to
• -Stop IVF
• -Remove all IV if other routes for necessary
  meds are available
• -Stop all blood draws
• -DC PT/OT, Routine vitals, Monitor equipment,
  Respiratory Tx if it does not give symptom
  relief.
• -Lift Visitation Restrictions
• -Offer to call the chaplain
• -Always have PRN morphine available