CHAPTER 9. NUTRITION
Suzanne W. Dixon
The issue of nutrition support in the palliative care environment is controversial. Between the extremes of solely appetite-driven dietary intake and feeding aggressively with enteral or parenteral nutrition until death lies the gray area of if, when, and how much to feed individuals with known terminal disease. Further complicating this issue are discrepant perceptions of the patient, family, and the clinician, as well as the cultural context in which death occurs. Many families equate feeding and nourishment with love (Poole & Froggatt, 2002), leading to a desire to aggressively feed the patient, even if this is not likely to improve comfort or length of life. For other families, past negative experiences with aggressive nutrition interventions lead to a rejection of nutrition support under all circumstances (Back & Arnold, 2005). And a study of advanced cancer patients in Europe has demonstrated that cultural values likely affect the decision to aggressively implement nutrition support (McKinlay, 2004).
The role of the clinician is to help patients and families navigate through this difficult and emotionally fraught time, while respecting patient autonomy, desires, and needs. The clinician is in the unique position to help involved individuals weigh the risks and benefits of various nutrition interventions and to determine whether aggressive intervention is likely to improve comfort, pain, and length of life in a meaningful way (Fine, 2006; Fuhrman & Herrmann, 2006).
DEFINITIONS
It is vitally important for the clinician to understand the difference between anorexia and cachexia. These terms often are used interchangeably, but they are not the same. Anorexia is a lack of appetite. Cachexia is the term used to describe the disordered metabolism characteristic of certain diseases and/or conditions including, but not limited to, cancer, sepsis, chronic infections, HIV/AIDS, congestive heart failure, chronic obstructive pulmonary disease, and other conditions resulting in systemic inflammation (Delano & Moldawer, 2006). Anorexia is a feature of cachexia, but anorexia does not cause cachexia. Cachexia and subsequent anorexia can lead to weight loss, loss of muscle mass, loss of functional status, and decline in length and quality of life for patients with advanced illnesses.
PATHOPHYSIOLOGY
The weight loss associated with simple anorexia can be ameliorated with appropriate energy and protein, because this condition is not characterized by the metabolic aberrations that underlie cachexia. The loss of weight, muscle mass, and functional status characteristic of cachexia cannot be addressed with calories and protein alone. If the underlying metabolic derangement of cachexia is not addressed, nutrition support is unlikely to halt weight loss, although it may improve quality of life. In this circumstance, nutrition intervention risks, such as increased discomfort and infection, and benefits, including improved quality of life, must be carefully considered.
The cause of cachexia is not completely understood, but it is thought to result from the overproduction of proinflammatory (procachectic) mediators called cytokines and interferons. Tumor necrosis factor, interleukins 1 and 6, interferon γ, and proteolysis-inducing factor are believed to be among the most important mediators in the cachexia response (Argiles, Busquets, & Lopez-Soriano, 2005; Deans, Wigmore, Gilmour et al., 2006; DeJong, Busquets, Moses et al., 2005; Delano & Moldawer, 2006; Tisdale, 2005). Current research is focusing on additional novel molecules and pathways that may play a role in the development and progression of cachexia, including ghrelin, leptin, myostatin, and the ubiquitin-proteasome pathway (Akashi, Springer, & Anker, 2005; Filippatos, Anker, & Kremastinos, 2005; Jespersen, Kjaer, & Schjerling, 2006; Wolf, Sadetzki, Kanety et al., 2006).
The presence of these mediators can result in anorexia, hypermetabolism, and alterations in normal metabolic pathways. In simple starvation, the healthy body readily adapts to a calorie deficit by decreasing metabolic rate and shifting to fatty acids as a primary energy source, thereby preserving lean body mass. In cachexia, the body fails to make this adaptation, which can lead to disproportionate wasting of lean body mass and loss of strength and functional status. This can lead to a decline in quality of life, comfort, and functionality of the patient who is terminally ill (Anker, Steinborn, & Strassburg, 2004; Cox & McCallum, 2000; Muscaritoli, Bossola, Aversa et al., 2006; Strasser & Bruera, 2002; Van Cutsem & Arends, 2005).
MANIFESTATIONS OF CACHEXIA
The primary manifestations of cachexia include, but are not limited to, anemia, anorexia, dehydration, early satiety, electrolyte imbalances, fatigue, loss of lean body mass, malaise, micronutrient deficiency, taste alterations, weakness, and weight loss. In the palliative care setting, the goal of nutrition intervention for cachexia is to address as many of these issues as possible to improve the quality of life and functionality without increasing discomfort, pain, fluid retention, or other symptoms.
Metabolic Abnormalities of Cachexia
Ideally, addressing the underlying metabolic abnormalities of cachexia is the first step to improved quality of life, functionality, and symptomatology in the palliative care setting. Unfortunately, pharmacologic interventions for cachexia have had limited success and are only appropriate in carefully selected patients (Strasser & Bruera, 2002; Wilcock, 2006).
The use of omega-3 fatty acids is one intervention designed to ameliorate the underlying metabolic aberrations of cachexia (Elia, Van Bokhorst-de van der Schueren, Garvey et al., 2006). Evidence suggests that the metabolic alterations that contribute to cancer cachexia can be normalized by increased intake of eicosapentaenoic acid (EPA), one type of omega-3 fatty acids (Barber, 2002; Barber & Fearon, 2001; Barber, Fearon, Tisdale et al., 2001; Barber, McMillan, Preston et al., 2000; Barber, Ross, Voss et al., 1999; Burns, Halabi, Claman et al., 1999; Harman, 2002; Jho, Babcock, Helton et al., 2003; Moses, Slater, Preston et al., 2004; Wigmore, Barber, Ross et al., 2000). Research on the benefits of EPA for addressing cachexia has been conducted predominantly in cancer populations. However, given that common pathophysiologic mechanisms appear to underlie cachexia that occurs in various disease states, it is reasonable to assume that administration of omega-3 fatty acids is a useful approach in all of these cases (Coletti, Moresi, Adamo et al., 2005; Hehlgans & Pfeffer, 2005; Witte & Clark, 2002).
Research has indicated that amounts up to 18 g/day of EPA are well tolerated (Barber & Fearon, 2001). The most common dose-limiting symptom is diarrhea (Barber & Fearon, 2001). It is important to note, however, that a dose of 2.2 g of EPA per day is believed to be effective and that this lower dose is associated with minimal risk of side effects (Fearon, Von Meyenfeldt, Moses et al., 2003; Moses et al., 2004).
Patient education is a key component of appropriate use of EPA. Three double-blind, placebo-controlled trials failed to find a benefit from an EPA-enhanced liquid nutritional supplement in cachectic cancer patients. However, in not one of these trials was the therapeutic minimum dose reached of 2.2 g of EPA per day (Bruera, Strasser, Palmer et al., 2003; Fearon et al., 2003; Jatoi, Rowland, Loprinzi et al., 2004). Furthermore, post-hoc analyses indicated a strong correlation between higher EPA intakes and significantly improved outcomes, including halt in weight loss, improved quality of life, and reductions in inflammatory biomarkers. These trials highlight the importance of educating patients on the therapeutic nature of an EPA-containing supplement so that this is not treated as simply “another supplement to try.”
EPA can be incorporated into the diet through specialized oral/enteral formulas such as RESOURCE Support (Novartis Medical Support) and ProSure (Ross/Abbott Laboratories) or EPA-containing fish oil supplements. Fish oil supplements are available in gelatin capsule and deodorized liquid form. For typical gelatin capsule supplements, approximately 8 to 10 capsules per day are required to reach 2.2 g of EPA. Many patients have difficulty swallowing pills, and for this group, the deodorized liquid form of fish oil may be a better option (The Very Finest Fish Oil [Carlson Laboratories] is an example of a liquid product that is well tolerated by many patients). Generally, it has been recognized that food sources of EPA do not provide a dose that is sufficient to halt cachexia.
MANAGEMENT OF NUTRITION IMPACT SYMPTOMS
The nature of appropriate nutrition intervention should be guided by the setting in which it occurs. Suggested interventions that can be used by the clinician when educating the patient and family in the palliative and end-of-life care settings include the following.
Palliative Care Setting
The caregiver must treat and manage the symptoms that may affect nutritional intake and interfere with the patient’s desire to eat, including constipation; bloating; diarrhea; feelings of fullness, early satiety, and poor appetite; altered sense of taste and smell; dry mouth and/or thick saliva; sore mouth and/or throat; nausea and/or vomiting; and pain.
Patient and Family Education Constipation
While many health care professionals dismiss constipation as a relatively trivial problem, resulting in a lack of attention to the subject, constipation is experienced by more than 50% of cancer patients (Smith, 2001), a group that comprises a significant proportion of the palliative care population. Constipation causes physical and emotional distress in patients who experience it, and the frequent use of pain management medications makes constipation common in the palliative care population (Staats, Markowitz, & Schein, 2004). Unfortunately, the need to treat constipation often is due to a failure to prevent it (Smith, 2001).
In addition to preventive constipation management medication protocols, which should be initiated prior to onset of constipation, nutrition intervention can be beneficial. While some literature suggests that constipation is not strongly related to dietary factors (Muller-Lissner, Kamm, Scarpignato, & Wald, 2005), numerous studies and reports indicate that nutrition can and should be an important part of constipation management (Geriatrics, 2005; Khaja, Thakur, Bharathan et al., 2005; Wilson, 2005; Wisten & Messner, 2005). It is important for the APN to encourage ongoing communication between the patient and family and their health care team about medication options that are useful for constipation management. Nutrition approaches work best in combination with medication. Suggested nutrition interventions for constipation include the following (American Cancer Society, 2006a; Dobbin & Hartmuller, 2000):
▪ Eat at regular times each day.
▪ Drink 8 to 10 cups of noncaffeinated fluid each day. If additional calories are needed to meet nutritional needs, focus on calorie-containing beverages including 100% fruit juices, milk, soy milk, rice milk, and any other tolerated beverages.
▪ Include water, prune juice (2 to 4 ounces to assess tolerance), warm juices, and teas as a portion of fluid intake. Drink two cups of warm liquid (can include coffee) with breakfast every day.
▪ Include foods high in insoluble fiber, only if tolerated. This includes whole-grain breads containing a minimum of 4 g of fiber per slice; cereals containing a minimum of 6 to 8 g of fiber per serving; whole-grain pastas; raw and cooked vegetables including skins and peels, such as apples, carrots, and green leafy vegetables; popcorn; and beans, such as navy beans, kidney beans, black beans, and lentils. If gas, bloating, and/or abdominal distention is present, do not increase insoluble fiber in the diet. Do not increase insoluble fiber if a low-residue diet has been prescribed.
▪ Eat a good breakfast that includes a hot drink and high-fiber foods, such as bran cereals, oatmeal, or Cream of Wheat (Kraft Foods).
▪ If additional calories are needed to meet nutritional needs, try a fiber-containing, high-calorie, high-protein, liquid supplement (e.g., Ensure Plus with Fiber [Ross/Abbott Laboratories]).
▪ Try adding in a fiber supplement such as Benefiber (Novartis Consumer Health) or Metamucil (Procter & Gamble). Benefiber may be better tolerated. Be sure patient consumes adequate fluids with fiber supplements.
▪ Try dried fruit such as apricots, figs, or raisins. If gas, bloating, and/or abdominal distention is present, do not increase insoluble fiber in the diet. Do not increase insoluble fiber if a low-residue diet has been prescribed.
Bloating*
The APN should encourage ongoing communication between the patient and family and their health care team about medication options for decreasing gas production. Nutrition approaches work best in combination with medication.
▪ Limit foods and drinks that cause gas, including carbonated beverages, broccoli, cabbage, cauliflower, cucumbers, peppers, beans, peas, onions, and garlic. A food and symptom diary can help identify other, individual triggers of gas and bloating from particular ingested foods.
▪ Lessen the amount of air swallowed by eating slowly and avoiding excessive talking while chewing and swallowing.
▪ Do not use straws to drink liquids.
▪ Avoid chewing gum.
Diarrhea†
†American Cancer Society, 2006b; Can, Besirbellioglu, Avci, et al., 2006; Chermesh & Eliakim, 2006; Coeffier, Hecketsweiler, Hecketsweiler et al., 2005; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; Heiser et al., 2004; Novak & Katz, 2006; Rushdi, Pichard, & Khater, 2004; Savarese, Savy, Vahdat et al., 2003; and Savarese, Al-Zoubi, & Boucher, 2000.
▪ Encourage ongoing communication between the patient and family and their health care team about medication options for managing diarrhea. Nutrition approaches work best in combination with medication.
▪ Increase intake of foods high in soluble fiber, including oatmeal, white rice, bananas, white toast, applesauce, and canned fruits without the skins, such as peaches and pears.
▪ Drink 6 to 8 cups of fluids each day to replace losses. Include nonwater beverages, such as Gatorade (Stokely-Van Camp, Inc.) or Pedialyte (Abbott Laboratories), to help replace lost electrolytes. Do not rehydrate solely with water; this can contribute to electrolyte abnormalities.
▪ Drink fluids at room temperature. Avoid very hot and very cold drinks.
▪ With each loose bowel movement, drink 1 additional cup of electrolyte-containing fluid, such as Gatorade or Pedialyte.
▪ Try nonacidic juices, such as apple juice, apricot nectar, peach nectar, or pear nectar.
▪ Sip broth and sports drinks to replace electrolyte losses.
▪ Eat very small, frequent meals. Encourage a “bite-at-a-time” approach to eating.
▪ Drink fluids between meals rather than with meals (e.g., separate liquids from solids).
▪ Lie down immediately after eating.
▪ Snack on salty, bland foods, such as crackers and pretzels, to replace lost sodium.
▪ Consider powdered glutamine (amino acid) supplement, mixed with liquid, at a dose of 10 g, three times daily (research-supported brands of glutamine include RESOURCE GlutaSolve [Novartis Medical Nutrition] and Sympt-X [Cambridge Nutraceuticals/Baxter Pharmaceuticals]). Glutamine may be contraindicated if renal and/or hepatic function is impaired.
▪ Try probiotic supplements that contain a broad spectrum of probiotic flora including Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus reuteri, Lactobacillus rhamnosus, Bifidobacterium bifidum, Bifidobacterium longum, and/or Streptococcus thermophilus.
▪ Avoid foods high in insoluble fiber, such as fresh fruit with the peel (the flesh of the fruit is okay), raw vegetables (well-cooked vegetables are okay), whole-grain breads and cereals, beans, peas, and popcorn.
▪ Limit fatty and greasy foods.
▪ Limit or eliminate dairy products (except yogurt) if helpful. Include yogurt to replace normal and healthy gut flora.
▪ Consider utilizing a rice congee that is made of 1 cup long-cooking rice combined with 6 cups water and 1 tablespoon of salt; cook according to package directions (typically about 40 minutes). Eat and drink this soupy mixture.
Feelings of Fullness, Early Satiety, and Poor Appetite*
▪ Incorporate a minimum of 2.2 g of EPA into the diet to halt cachexia, which may be contributing to poor appetite. EPA can be incorporated into the diet through specialized oral/enteral formulas such as RESOURCE Support (Novartis Medical Support) and ProSure (Ross/Abbott Laboratories) or EPA-containing fish oil supplements. Fish oil supplements are available in gelatin capsule and deodorized liquid form. Patients and families must be educated to reach therapeutic dose (at least 2.2 g of EPA per day) to maximize possibility of benefit.
▪ Assess zinc status and supplement as indicated.
▪ Avoid intake of noncaloric beverages such as water and tea in large quantities.
▪ Eat very small, frequent meals. Encourage a “bite-at-a-time” approach to eating.
▪ Focus on eating one to two bites every 20 minutes throughout the day.
▪ Make eating more enjoyable by setting an attractive table, playing favorite music, or watching television.
▪ Eating is a social activity. If patient is unable to eat at the table, have family join patient where he or she is able to eat. Prevent patient from eating alone, if at all possible.
▪ Keep snacks handy to eat immediately (hunger may last only a few minutes), such as granola bars; nuts; pudding cups; chips; crackers; pretzels; single serving sizes of tuna, chicken, or fruit; dried fruit; and/or trail mix.
▪ Eat favorite foods at any time of the day; for example, if breakfast foods are appealing, eat them for dinner. No foods are off-limits.
▪ Eat every hour at a minimum—do not wait until hungry. Relying on appetite is not a good guide when introducing appropriate nutrition.
▪ Treat food like medicine—set times to eat, such as every 30 minutes to 1 hour and encourage at least one or two bites of any food during “medication” times (quantity and type of food are less important; frequency of eating is more important).
▪ Consider fortified juice-based supplements such as Enlive! (Ross/Abbott Laboratories) if taste fatigue of other “creamy” textured supplements is a problem.
▪ Encourage fluids between meals, rather than with meals (e.g., separate liquids from solids). Liquids can cause stomach distension and worsen feelings of fullness, making intake of calorie-rich solids problematic.
Altered Sense of Taste and Smell*
*American Cancer Society, 2006h; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; Heckmann et al., 2005; Polisena, 2000; Ripamonti et al., 1998; and Shay & Mangian, 2000.
▪ Encourage ongoing communication between the patient and family and their health care team about specific conditions that can create unpleasant mouth taste. For example, infections such as thrush and zinc deficiency can alter sense of taste and smell. These problems can be treated with medication and/or nutritional supplementation. Nutrition approaches work best when combined with medication.
▪ If indicated, use a zinc supplement of 220 mg of zinc sulfate two times per day. Use supplement for up to 3 months. Short-term zinc supplementation may help with altered sense of taste, but long-term zinc supplementation may contribute to impaired immune status, micronutrient malabsorption, and other health problems.
▪ Provide education on fastidious mouth care to prevent secondary bacterial infections.
▪ Avoid food smells.
▪ Consider foods that have minimal odors and short cooking time, such as scrambled eggs, plain pasta, yogurt, pudding, oatmeal, and Cream of Wheat.
▪ Season foods with tart flavors such as lemon, citrus, vinegar, and pickled items (avoid if sore mouth or throat is present).
▪ Flavor foods with spices not normally used, such as basil, oregano, rosemary, tarragon, mustard, catsup, or mint.
▪ Marinate and cook meats in sweet juices, fruits, dressings, or wine, such as sweet and sour pork, chicken with honey glaze, or beef with Italian dressing.
▪ Rinse mouth with tea, ginger ale, saltwater, or baking soda and water to clear taste buds prior to eating.
▪ Suck on lemon drops or mints or chew gum ( avoid if sore mouth or throat is present; avoid sugarless gums and candies if diarrhea is present).
▪ Encourage patient to experiment often. Very unusual flavors, such as a pickle juice milk shake, may be acceptable to a patient with altered sense of taste and smell.
Dry Mouth and Thick Saliva†
†American Cancer Society, 2006c, 2006d; American Institute for Cancer Research, 2006; Cox & McCallum, 2000; Dobbin & Hartmuller, 2000; and Guggenheimer & Moore, 2003.
▪ Encourage ongoing communication between the patient and family and the health care team about what is creating a dry mouth and/or thick saliva. Medication options may be available to alleviate severe xerostomia. Nutrition approaches work well in combination with medications.
▪ Drink 8 to 12 cups of liquid a day and take a water bottle when leaving the house (adequate and even extra fluids can help loosen mucus). Use nonacidic juices and other high-calorie liquids to increase calorie intake if weight loss is a problem.
▪ Consider 100% papaya juices or eating papayas, which contain an enzyme (papain) that can help to break up thick saliva.
▪ Introduce 100% pineapple juice or pineapple, which can help to thin mucus (avoid if sore mouth or throat is present).
▪ Use a straw to drink liquids to bypass mouth sores (avoid if bloating and gas are present).
▪ Eat soft foods at room temperature or cold. Try blenderized fruits and vegetables, soft-cooked chicken and fish, well-thinned cereals, Popsicles, and shakes/smoothies made with juices and fruit; if dairy foods increase mucus production, try making a smoothie with a nondairy alternative such as soy or rice milk).
▪ Try limiting intake of dairy products, which may promote mucus secretions; use a nondairy alternative such as soy or rice milk.
▪ Suck on lemon drops (avoid if sore mouth or throat is present) or frozen grapes or ice chips ( do not chew ice, as this can damage teeth).
▪ Try mixing 1 cup of peach or papaya nectar with 1/2 cup of club soda and drink (avoid if sore mouth or throat is present).
▪ Avoid commercial mouthwashes; these contain alcohol, which is drying.
▪ Try alcohol-free mouthwashes and gums, such as Biotene (Laclede).
▪ Avoid alcoholic beverages, caffeinated beverages, chocolate, and tobacco products. These are drying to the mouth.
▪ Use a cool mist humidifier to moisten room air (keep clean to avoid spreading bacteria, fungi, or mold).
Sore Mouth and Throat*
*American Cancer Society, 2006f, 2006g; American Institute for Cancer Research, 2006; Anderson, Schroeder, & Skubitz, 1998; Anonymous, 2005; and Peterson, 2006.
▪ Encourage ongoing communication between the patient and family and their health care team about medication options for managing mouth and throat pain. Nutrition approaches work best in combination with medication.
▪ Encourage fastidious mouth care to prevent secondary bacterial infections.
▪ Eat soft, bland foods, such as creamed soups, cooked cereals, macaroni and cheese, yogurt, pudding, mashed potatoes, eggs, custards, casseroles, cheese cake, and milk shakes or smoothies.
▪ Drink through a straw to bypass mouth sores (avoid if bloating is present).
▪ Eat high-protein, high-calorie foods to promote healing.
▪ Consider a powdered glutamine (amino acid) supplement, dissolved into warm water, at a dose of 10 g, three times daily (research-supported brands of glutamine include RESOURCE GlutaSolve [Novartis Medical Nutrition] and Sympt-X [Cambridge Nutraceuticals/Baxter Pharmaceuticals]). Swish and swallow the glutamine mixture for best results. Glutamine may be contraindicated if renal and/or hepatic function is impaired.
▪ Soften foods such as bread by soaking in milk.
▪ Stick to nonacidic juices such as apple juice; peach, pear, or apricot nectars; and grape juice (do not use grape juice if diarrhea is present).
▪ Avoid tart, acidic, or salty beverages and foods such as citrus, pickled items, and tomato-based foods.
▪ Avoid alcohol, caffeine, and tobacco.
Nausea and Vomiting*
*Bruera et al., 2003; Fearon et al., 2003; Harman, 2002; Jho et al., 2003; Moses et al., 2004; and Polisena, 2000.
▪ Incorporate a minimum of 2.2 g of EPA into the diet to halt cachexia, which may be contributing to poor appetite. EPA can be incorporated into the diet through specialized oral/enteral formulas such as RESOURCE Support (Novartis Medical Support) and ProSure (Ross/Abbott Laboratories) or EPA-containing fish oil supplements. Fish oil supplements are available in gelatin capsule and deodorized liquid form. Patients and families must be educated to reach therapeutic dose (≥2.2 g of EPA per day) to maximize possibility of benefit.
▪ Encourage ongoing communication between patient and family and the health care team about medication options to manage nausea and vomiting. Encourage the use of medications as prescribed, even if not feeling nauseous. Educate that it is easier to prevent nausea and vomiting than it is to treat it. Nutrition approaches are ineffective if intractable, untreated nausea and vomiting are present.
▪ Eat small frequent meals and snacks to avoid an empty stomach, which may worsen nausea.
▪ Eat bland foods such as oatmeal, pasta, rice, plain pancakes, and potatoes.
▪ Try warm salty foods and liquids, such as soups or broths, and cooked hot cereals such as oatmeal or Cream of Wheat.
▪ Try dry salty foods, such as crackers, toast, dry cereal, or breadsticks, every 1 to 2 hours.
▪ Avoid offensive food smells.
▪ Have someone other than the patient prepare his or her food.
▪ Consider foods that have minimal odors and short cooking time, such as scrambled eggs, plain pasta, yogurt, pudding, shakes and smoothies, oatmeal, Cream of Wheat, plain baked chicken, or instant mashed potatoes.
▪ Avoid eating in a room that is uncomfortably warm or has poor ventilation.
▪ Rinse out mouth before and after meals.
▪ Sip warm, flat ginger ale.
▪ Sip ginger tea, chamomile tea, or peppermint tea (avoid peppermint tea and other peppermint-flavored foods if reflux is present).
▪ Position in a sitting position when eating.
▪ Do not lay down after eating for at least 1 hour.
▪ Consider limiting dairy products if helpful.
▪ Avoid overly sweet, fatty, fried, or rich foods such as desserts and French fries.
Pain
▪ Provide appropriate analgesics. Unmanaged, intense pain can contributes to lack of appetite and inability to eat. In the presence of unmanaged pain, eating is of little importance.
▪ Encourage ongoing communication between the patient and family and the health care team to ensure optimal pain management. Educate that there are many options for pain management and that different medications can be tried.
Enteral Nutrition Support
Enteral nutrition is an aggressive intervention but is appropriate to support the patient if it will improve quality and/or length of life in a meaningful way (Cox, 2006; Dormann, 2004; Hopkins, 2004; Lundholm, Daneryd, Bosaeus et al., 2004). Enteral nutrition should be given only when the patient wants it, is motivated to learn and follow the instructions on tube feeding, and has a functioning gut.
Enteral nutrition is not necessarily contraindicated by conditions such as intractable nausea and vomiting, obstruction, or gastroparesis. It may be possible to bypass these issues/areas with a jejunal feeding tube instead of a gastric feeding tube. Indications include patients who fail to meet a minimum of 50% of required nutrient needs orally for 5 days or longer or who have protein-energy malnutrition and severe dysphagia. Contraindications for this intervention include intestinal obstruction distal to the feeding site; ileus; unmanageable hypomotility of the intestine; severe, intractable diarrhea that is unresponsive to treatment including resolution of underlying infection, antidiarrheal medications, and diet modifications; high output enterocutaneous fistulas; and acute pancreatitis.
Enteral nutrition is contraindicated if the prognosis does not warrant aggressive nutritional support. This is an individual decision that must be discussed with the patient and family and managed on a case-by-case basis. Issues to consider include patient desires and needs, mores and values, cultural context, and sociofamilial issues.
Research has indicated that enteral feeding is used more often in for-profit settings and when state-stipulated weight loss and dehydration regulations are present (Cox, 2006). This finding is important because in certain disease states, such as dementia, tube feeding is not proven to reduce rates of aspiration pneumonia, pressure sores, or infections. Furthermore, tube feeding does not prolong survival, improve function, or provide palliation in this population (Finucaine, Christmas, & Travis, 1999; Li, 2002). All of these issues must be considered and discussed honestly with the patient and the family to allow for an informed choice regarding enteral nutrition.
Initiating enteral nutrition includes the following steps:
▪ Consult a registered dietitian (RD) to determine nutrient needs and to select formula (e.g., high protein, fiber containing, elemental, etc.) and administration method (pump, gravity feeding, or bolus feeding).
▪ Troubleshoot common, simple enteral feeding problems (Table 9-1).
| *Contact a registered dietitian or physician if these measures fail to correct the problem. |
||
| Problem | Possible Causes | Solutions |
|---|---|---|
| Feeding Tube Clog | Inadequate flushing before or after administering feedings and/or medications. Attempting to place anything other than enteral feeding formula, water, or crushed and dissolved medications through the tube. | Attempt to flush tube with a syringe filled with 30 ml of warm water. If unsuccessful, fill syringe with water again and move plunger back and forth gently several times until tube clears. Avoid excessive force when trying to unclog a feeding tube. Use a product designed to dissolve enteral feeding clogs, such as Viokase or a similar product. If unsuccessful, call your home care nurse, physician, or registered dietitian. |
| Note: DO NOT try to clear blockage by inserting an object into the tube as this could injure the stomach lining or damage the tube. DO NOT use cranberry juice, other juices, meat tenderizer, soda, colas, or any other carbonated beverage to attempt to unclog tube. These products cause the protein in tube feeding formulas to coagulate, form clogs, and worsen existing clogs. | ||
| Leakage Around the Tube | Improper positioning, such as laying flat during feeding. | Sit at least 45 degrees upright during feeding and for at least 1 hour after feeding. Slow the feeding rate by ¼ to ½. If it appears that the tube is clogged, use instructions above to unclog tube. To check for the tube being out of position, measure the length of the tube or locate the mark on tube. If the tube is longer than it should be compared to when it was first placed or if the mark is further out that just flush with your skin, contact your health care provider immediately—the tube may need to be replaced. |
| Feeding too rapidly. A blocked tube. The tube is out of position. | ||
| Diarrhea | Feeding too rapidly. Using a formula with an osmolality that is too high. Using a formula without any fiber. | Slow the feeding rate by ¼ to ½ the previous feeding rate. Switch to an isotonic formula. Flavored, oral liquid products such as Ensure or Boost are not designed for tube feeding and can cause diarrhea, especially if the tube is placed in the jejunum rather than the stomach. Change all or some of the feeding formula to a fiber containing formula. Use an elemental formula or a formula that contains medium-chain triglycerides as the fat source to address malabsorption. |
| Maldigestion/malabsorption | ||
▪ Address micronutrient deficiencies: If patient is not close to death, the use of vitamin and mineral supplements, such as an iron supplement for iron deficiency anemia (microcytic), or vitamin B 12 and folic acid supplements (for macrocytic/megaloblastic anemia), may be beneficial. However, the benefit of micronutrient supplementation must be weighed against potential discomfort it may cause. For example, iron supplementation can exacerbate constipation and may contribute to nausea. It may be more beneficial to discontinue vitamin and mineral supplements that contribute to gastrointestinal stress, nausea, constipation, or diarrhea if these conditions diminish quality of life to a significant degree. This issue must be discussed with the patient, family, and other caregivers. The risks and benefits of supplementation should be decided on a case-by-case basis.
Parenteral Nutritional Support*
*Bruera et al., 2005; Mirhosseini, Fainsinger, & Baracos, 2005; Morita et al., 2005; Orrevall, Tishelman, & Permert, 2005; Orrevall et al., 2004; and Plonk & Arnold, 2005.
In select cases, the use of parenteral nutrition may be warranted. If the prognosis is more than 3 months to live and no other route of administration is available, parenteral nutrition may provide some benefit to the patient who is receiving palliative care. A study by the Japan Palliative Oncology Study Group indicated that artificial hydration can alleviate dehydration signs but may worsen peripheral edema, ascites, and pleural effusions (Morita, Hyodo, Yoshimi et al., 2005). Potential benefits of artificial hydration therapy and parenteral nutrition must be balanced against the risk of worsening fluid retention. This is an excellent example of how the physical costs and benefits of an aggressive supportive intervention must be weighed to allow for informed choice by the patient and family.
Parenteral nutrition may be inappropriate for the following reasons:
▪ It does not add quality or length of life.
▪ The risks, including infection, hepatic and renal complications, and fluid management, often outweigh the benefits.
▪ It is costly.
▪ It is invasive.
▪ It requires frequent blood work (no less than weekly) and intensive management by a nutrition support RD or pharmacist.
▪ It can contribute to and/or exacerbate other complications including ascites, edema, and hepatic and renal dysfunction.
The most important role for the palliative care clinician is to educate the patient and family on the risks and benefits of parenteral nutrition on a case-by-case basis. The request for parenteral nutrition from a family may be driven by a desire to provide nourishment and support. Providing the patient and family with an understanding of the potential complications and discomfort of parenteral nutrition will allow the patient and the family to make an informed choice.
Pharmacologic Support
Table 9-2 identifies the basic pharmacologic approaches for managing select nutrition-impact symptoms that commonly occur in patients in the palliative care environment.
| Symptom | Pharmacologic Options |
|---|---|
| Sore mouth and mucositis | Equal parts Benadryl (diphenhydramine), viscous lidocaine, and Maalox (aluminum hydroxide/magnesium hydroxide) or Mylanta (aluminum hydroxide/magnesium hydroxide/simethicone) |
| Equal parts Nystatin, Maalox, Benadryl, and viscous lidocaine | |
| Thick saliva and dry mouth | Guaifenesin (expectorant) |
| Saliva stimulators: Salagen tablets (pilocarpine hydrochloride) | |
| Saliva replacers: Xero-Lube (sodium fluoride), Salivart (carboxymethylcellulose sodium), Moi-Stir (carboxymethylcellulose sodium), Salix (carboxymethylcellulose sodium), Optimoist (hydroxyethyl cellulose) | |
| Mouth moisturizers | |
| Lack of appetite | Megestrol acetate (Megace) |
| Dexamethasone (Decadron) | |
| Dronabinol (Marinol) | |
| Cyproheptadine (antihistamine) | |
| Fluoxymesterone (androgenic) | |
| Selective serotonin reuptake inhibitors | |
| Ritalin | |
| Constipation | Over-the-counter constipation medications used in combination as directed by nursing staff and medical care team to relieve constipation; prevention is key. |
| Nausea and vomiting | First-line antiemetics: dopamine antagonists, serotonin receptor antagonists, corticosteroids, dopamine antagonists, butyrophenones, phenothiazines, benzodiazepines, antihistamines |
| Marinol | |
| Erythromycin | |
| Metoclopramide (Reglan) |
▪ Cyproheptadine hydrochloride (Periactin)—slight increase in appetite and intake with use of this agent; may not prevent persistent weight loss but may improve quality of life due to improved appetite (Mattox, 2005)
▪ Cannabinoids (dronabinol [Marinol])—5 to 10 mg orally twice daily—increased appetite, decreased nausea, trend toward stabilized weight; may be particularly beneficial for anorectic patients at end-of-life (Morley, 2002; Walsh, Nelson, & Mahmoud, 2003)
▪ Corticosteroids—decreased nausea, increased sense of well-being, and increased appetite have been documented, but beneficial effects are time-limited and should be weighed against long-term adverse effects that may include Cushing’s syndrome, proximal myopathy, immunosuppression, steroid-induced diabetes, and exacerbation of delirium (Tisdale, 2006)
▪ Megestrol acetate (Megace)—800 mg/day orally—a number of studies demonstrate beneficial effects on appetite and weight gain at 800 mg/day dosage; more effective in men when given with testosterone; may be more effective than dronabinol in advanced cancer patients; possible side effects include edema, thrombosis, and vaginal bleeding; should not be used in bed-bound patients due to risk of deep vein thrombosis (Jatoi, Windschitl, Loprinzi et al., 2002; Morley, 2002; Pascual Lopez, Rogue i Figuls, Urrutia Cuchi et al., 2004).
End-of-Life Care Setting
Patient and family education on the dying process and on “what to expect” as death approaches is one of the most important roles of the clinician in the palliative care setting (American Medical Association, 2001; Beider, 2005; McKinlay, 2004). It is important to inform the patient and family on the following aspects of death and dying:
1. A decrease in food and fluid intake is a normal part of the “physiology” of dying.
2. In the last weeks to days of life, there is a marked decline in upper and lower gastrointestinal functioning, as well as a decrease in the senses of taste and smell. Education of family members and caregivers at this stage is very important.
3. The physical sensations of “starving” are not present at end-of-life. The patient feels little discomfort from decreasing nutritional status. Hunger is nonexistent. Forcing the issue of food is counterproductive and can result in resentment and a decreased quality of life.
4. Maintenance of strength and nutritional status at this time is unrealistic. Caregivers should be encouraged to show love and support in ways that do not involve the preparation or provision of food.
5. Dehydration is a normal part of the end-stage of the dying process. Often, the only discomfort associated with dehydration is a dry mouth. This can be alleviated with sips of water, ice chips, or moistened swabs.
6. Artificial hydration should be evaluated and used appropriately.
7. If artificial hydration or nutrition support is already in place, decreasing the amount of the infusion to 500 to 600 ml/day may help to avoid discomfort from increased urinary output, gastrointestinal and pharyngeal secretions, and pulmonary edema. Stopping hydration altogether is an option if desired by the patient and family.
8. According to the American Medical Association Code of Ethics, human dignity is the primary obligation if it conflicts with prolonging life. All competent patients have the right to accept or reject any form of medical treatment, including artificial hydration and nutrition. If an advance directive is in place, this should specify patient desires with regard to supportive interventions, including fluids and artificial nutrition, at end-of-life.
9. If a patient expresses a desire to undertake voluntary cessation of eating and drinking, the following issues must be considered and addressed:
a. Patient characteristics: Persistent, unrelenting, otherwise unrelievable symptoms that are deemed unacceptable to patient and family, including, but not limited to, pain, seizures, weakness, and extreme fatigue
b. Patient informed consent
(1) Patient must be fully competent.
(3) Patient must be evaluated by a mental health professional to rule out treatable depression or other mental health conditions; a second opinion is strongly recommended.
(4) A written informed consent is in place.
c. Terminal prognosis: typically days to weeks
d. Palliative care: Must be available, in place, and unable to adequately relieve suffering.
e. Family participation: Clinicians should strongly encourage frank discussion. Consensus should be reached, if possible, among patient, immediate family members, and caregivers.
f. Patient incompetence: Food and fluids (oral) must not be denied from incompetent patients who are willing and able to eat.
g. Second opinions: Must be obtained from experts in underlying disease, mental health, pain management, and palliative care.
10. If all of these issues are addressed and managed, voluntary refusal of food and fluids may be an appropriate option. Artificial nutrition and hydration is considered a life-sustaining medical therapy similar to medications, surgery, dialysis, mechanical ventilation, or other medical interventions. Decisions regarding this issue should be handled under the same ethical and legal standards as other medical interventions. If the benefits of an intervention outweigh the costs, it is justified. If it is not beneficial or if, for this patient, the costs are higher than the benefits, it is not justified. Discontinuation of nutrition and hydration generally is not considered justified in the following situations.
a. The patient will die of malnutrition before he or she would succumb to the disease process. Example: Patient with severe dysphasia secondary to head and neck cancer, in whom the primary diagnosis will not result in death before malnutrition, if nutrition support and hydration are not provided.
b. There are untreated mental health issues such as depression.
c. The patient has a strong desire to “get affairs in order” such as writing a will or attending a specific family event.
d. A new acute, but treatable, diagnosis arises.
PATIENT OUTCOMES
The goal of palliative nutrition care should include the following outcomes:
▪ Anemia, anorexia, dehydration, early satiety, electrolyte imbalances, fatigue, loss of lean body mass, malaise, micronutrient deficiency, taste alterations, weakness, and weight loss are corrected when feasible.
▪ When maintenance of nutritional and hydration status are no longer reasonable goals, patient’s discomfort is addressed, such as providing ice chips for a dry mouth.
▪ When maintenance of nutritional status and strength are no longer reasonable goals, patient’s desires are addressed, such as providing whatever food and nutrition the patient wants (e.g., provision of favorite foods even if doing so does not improve nutritional status or meet nutritional needs).
▪ Patient maintains control over his or her intake.
PROFESSIONAL COMPETENCIES
▪ Assess and evaluate early manifestations of cachexia/anorexia and dehydration in order to ensure timely and beneficial interventions.
▪ Initiate interventions used to increase appetite and dietary intake, and calories, when feasible.
▪ Identify the risks and benefits of artificial nutrition and hydration and include the evaluation of the invasive nature of such interventions.
▪ Evaluate the effectiveness of interventions and modify the treatment plan to optimize patient comfort and dignity.
MEASUREMENT INSTRUMENTS
▪ Twenty-four–hour food recall
▪ Comprehensive diet history
▪ Nutrition needs assessment (calorie and fluid needs for maintenance of nutrition and hydration status)
▪ Laboratory measures, if available, including comprehensive metabolic panel and measures of micronutrient status
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