Nutrition 31 (2015) 615–616
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Nutritional support at the end of life Ylva Orrevall Ph.D., R.D. * Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden
a b s t r a c t Keywords: Elderly End of life Nutritional support Oncology
For patients with cancer at the end of life the goal of nutritional care is to optimize quality of life and comfort. Food and drink should be served as requested by the patient but without exerting pressure. For patients who have developed cachexia and are potentially candidates to receive artificial nutrition, discussions between the patient, family and health care team are needed to set the goals of nutritional care, considering both the risk of adverse effects of the treatment and ethical issues. The premise for a benefit from parenteral nutrition is that survival of the tumor spread exceeds that of starvation (usually by about 2-3 months). Ó 2015 Elsevier Inc. All rights reserved.
Palliative care is an approach that aims at improvement of the quality of life of patients and their families who face problems associated with life-threatening illness [1]. When there are no tumor-specific treatment options left to prolong the elderly patient’s life, the patient is considered to be in a late phase. This phase is often associated with cancer cachexia, which can be refractory both to antitumoral treatment and to nutritional support. Refractory cachexia has been suggested to be associated with a state of involuntary weight loss including muscle wasting, a low performance status (40 KPS), and expected survival less than 3 mo [2]. In clinical practice, it is fundamental to identify the point in the patient’s trajectory where the patient’s condition can no longer be expected to improve by means of nutritional support, as nutrients can no longer be normally metabolized [2,3]. The scientific evidence regarding artificial nutrition (enteral and parenteral nutrition) at the end of life is limited. Unfortunately the term “end of life” is very ambiguous, and patients can survive for a period ranging from few months to few days, with little ability by the caregivers to predict the length of survival. A more pragmatic approach would be to try to estimate if the cancer spread allows the patient a survival longer than 3 mo. No benefit can theoretically be expected by an active nutritional support if a starving patient is going to die of tumor progression within that time interval. The goal of nutritional care at the end of life needs to change from maintaining nutritional status and function to solely ensuring well-being and comfort for the patient [3,4]. A * Corresponding author. Tel.: þ46701671112. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.12.004 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
transition with a gradual reduction of food intake is a normal part of the dying process. Because of the symbolic value of food as a source of life, the end-of life care of the patient is demanding. Reduced food intake and involuntary weight loss can be a source of conflict between the patient and his/her family members [5], as well as a challenge to health professionals [6]. Extensive communication within the health care team and psychosocial support to patient and/or family is important in alleviating distress concerning food intake and weight loss, and in eliminating false expectations of the benefits of nutritional intake [5]. The patients should be supported in drinking and eating, but without being subject to persuasion or pressure [4,7]. Some patients might experience that the sight, smell, taste, and the mere thought of food make eating impossible [8]. When the goal of nutritional care is comfort alone, there is no need to assess nutritional status (for example weight) or measure food intake, unless such measurement has a clear purpose. Consumption of oral nutritional supplements and energy- and protein-enriched food needs no longer be encouraged. If the patient wishes to eat, normal institutional meals might not be appropriate if life expectancy is short, instead, personal wishes for food and drinks should be attended to. It is valuable to be able to offer a selection of soft foods that are easy to eat and digest and can be quickly prepared at the ward, for example small portions of soups, porridge, pancakes, egg dishes and custard, yogurt, ice cream, as well as refreshing drinks. Food restrictions, for example, diabetic diet and heart healthy diet, aiming at reducing sugar, salt and/or fat are seldom of importance for elderly cancer patients and especially not in the late palliative phase [4,9,10]. Food enjoyment might be increased if
616
Y. Orrevall / Nutrition 31 (2015) 615–616
restrictions are removed. Diet modifications can be valuable to meet food preferences, to facilitate chewing and swallowing, and to alleviate distressing gastrointestinal symptoms. To make mealtimes as pleasant as possible, it is equally important to offer the frail elderly patient cutlery and drinking devices to facilitate eating, as well as ensure a comfortable feeding position. To support the potential intake of comfort food, distressing symptoms such as dry mouth, pain, constipation, nausea, and vomiting should be identified and treated [1–4]. For patients who are in late palliative stage with refractory cachexia and a very short life expectancy but are still receiving artificial nutrition discussions among patient, family, and the health care team, which consider ethical issues, are needed to set the goals of nutritional care. In most cases, the best alternative is to stop the artificial nutrition altogether, as the burdens and risks of the treatment are likely to outweigh any potential benefits [2,3]. In some cases, it might be preferable to slowly reduce the infusion’s volume and rate [7] and change to products with less energy and protein density, with consideration given to patient/family preferences and ethical considerations. If artificial nutrition is requested from the patient and/or family members, it is important to investigate the underlying reasons and their hopes and expectations regarding this treatment. It is ethically problematic to perform studies at the end of life and very few studies have investigated this question [11,12]. Therefore, decisions need to be made after discussions with the patient and family, carefully considering each patient’s situation, and taking ethical issues into consideration as well as identifying adverse events so the risks of the treatment can be balanced against expected benefits [7,11,12]. If artificial nutrition is
administered, clear patient-centered goals and time frames for evaluation need to be decided upon. References [1] WHO. WHO definition of palliative care. Available at: http://www.who.int/ cancer/palliative/definition/en/. Accessed May 4, 2012. [2] Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia: An international consensus. Lancet Oncol 2011;12:489–95. [3] Oberholzer R, Blum D, Strasser F. The concept of cachexia-related suffering (CRS) in palliative cancer care. In: Preedy VR, editor. Diet and nutrition in palliative care. CPC Press; 2011. p. 245–55. [4] Maillet J. Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc 2008;108: 873–82. [5] Hopkinson JB. The emotional aspects of cancer anorexia. Curr Opin Support Palliat Care 2010;4:254–8. [6] van der Riet P, Good P, Higgins I, Sneesby L. Palliative care professionals’ perception of nutrition and hydration at the end of life. Int J Palliat Nurs 2008;14:145–51. [7] Ellershaw J, Wilkinson S. Care of the dying: A pathway to excellence. 2nd ed. Oxford: University Press; 2011. [8] Shragge JE, Wismer WV, Olson KL, Baracos VE. Shifting to conscious control: Psychosocial and dietary management of anorexia by patients with advanced cancer. Panminerva Med 2007;21:227–33. [9] Niedert KC. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc 2005;105:1955–65. [10] Darmon P, Kaiser MJ, Bauer JM, Sieber CC, Pichard C. Restrictive diets in the elderly: Never say never again? Clin Nutr 2010;29:170–4. [11] Good P, Cavenagh J, Mather M, Ravenscroft P. Medically assisted nutrition for palliative care in adult patients. Cochrane Database Syst Rev 2008;4:CD006274. [12] Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011;22:1478–86.
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Nutritional support at the end of life Ylva Orrevall Ph.D., R.D. * Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Sweden
a b s t r a c t Keywords: Elderly End of life Nutritional support Oncology
For patients with cancer at the end of life the goal of nutritional care is to optimize quality of life and comfort. Food and drink should be served as requested by the patient but without exerting pressure. For patients who have developed cachexia and are potentially candidates to receive artificial nutrition, discussions between the patient, family and health care team are needed to set the goals of nutritional care, considering both the risk of adverse effects of the treatment and ethical issues. The premise for a benefit from parenteral nutrition is that survival of the tumor spread exceeds that of starvation (usually by about 2-3 months). Ó 2015 Elsevier Inc. All rights reserved.
Palliative care is an approach that aims at improvement of the quality of life of patients and their families who face problems associated with life-threatening illness [1]. When there are no tumor-specific treatment options left to prolong the elderly patient’s life, the patient is considered to be in a late phase. This phase is often associated with cancer cachexia, which can be refractory both to antitumoral treatment and to nutritional support. Refractory cachexia has been suggested to be associated with a state of involuntary weight loss including muscle wasting, a low performance status (40 KPS), and expected survival less than 3 mo [2]. In clinical practice, it is fundamental to identify the point in the patient’s trajectory where the patient’s condition can no longer be expected to improve by means of nutritional support, as nutrients can no longer be normally metabolized [2,3]. The scientific evidence regarding artificial nutrition (enteral and parenteral nutrition) at the end of life is limited. Unfortunately the term “end of life” is very ambiguous, and patients can survive for a period ranging from few months to few days, with little ability by the caregivers to predict the length of survival. A more pragmatic approach would be to try to estimate if the cancer spread allows the patient a survival longer than 3 mo. No benefit can theoretically be expected by an active nutritional support if a starving patient is going to die of tumor progression within that time interval. The goal of nutritional care at the end of life needs to change from maintaining nutritional status and function to solely ensuring well-being and comfort for the patient [3,4]. A * Corresponding author. Tel.: þ46701671112. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.12.004 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
transition with a gradual reduction of food intake is a normal part of the dying process. Because of the symbolic value of food as a source of life, the end-of life care of the patient is demanding. Reduced food intake and involuntary weight loss can be a source of conflict between the patient and his/her family members [5], as well as a challenge to health professionals [6]. Extensive communication within the health care team and psychosocial support to patient and/or family is important in alleviating distress concerning food intake and weight loss, and in eliminating false expectations of the benefits of nutritional intake [5]. The patients should be supported in drinking and eating, but without being subject to persuasion or pressure [4,7]. Some patients might experience that the sight, smell, taste, and the mere thought of food make eating impossible [8]. When the goal of nutritional care is comfort alone, there is no need to assess nutritional status (for example weight) or measure food intake, unless such measurement has a clear purpose. Consumption of oral nutritional supplements and energy- and protein-enriched food needs no longer be encouraged. If the patient wishes to eat, normal institutional meals might not be appropriate if life expectancy is short, instead, personal wishes for food and drinks should be attended to. It is valuable to be able to offer a selection of soft foods that are easy to eat and digest and can be quickly prepared at the ward, for example small portions of soups, porridge, pancakes, egg dishes and custard, yogurt, ice cream, as well as refreshing drinks. Food restrictions, for example, diabetic diet and heart healthy diet, aiming at reducing sugar, salt and/or fat are seldom of importance for elderly cancer patients and especially not in the late palliative phase [4,9,10]. Food enjoyment might be increased if
616
Y. Orrevall / Nutrition 31 (2015) 615–616
restrictions are removed. Diet modifications can be valuable to meet food preferences, to facilitate chewing and swallowing, and to alleviate distressing gastrointestinal symptoms. To make mealtimes as pleasant as possible, it is equally important to offer the frail elderly patient cutlery and drinking devices to facilitate eating, as well as ensure a comfortable feeding position. To support the potential intake of comfort food, distressing symptoms such as dry mouth, pain, constipation, nausea, and vomiting should be identified and treated [1–4]. For patients who are in late palliative stage with refractory cachexia and a very short life expectancy but are still receiving artificial nutrition discussions among patient, family, and the health care team, which consider ethical issues, are needed to set the goals of nutritional care. In most cases, the best alternative is to stop the artificial nutrition altogether, as the burdens and risks of the treatment are likely to outweigh any potential benefits [2,3]. In some cases, it might be preferable to slowly reduce the infusion’s volume and rate [7] and change to products with less energy and protein density, with consideration given to patient/family preferences and ethical considerations. If artificial nutrition is requested from the patient and/or family members, it is important to investigate the underlying reasons and their hopes and expectations regarding this treatment. It is ethically problematic to perform studies at the end of life and very few studies have investigated this question [11,12]. Therefore, decisions need to be made after discussions with the patient and family, carefully considering each patient’s situation, and taking ethical issues into consideration as well as identifying adverse events so the risks of the treatment can be balanced against expected benefits [7,11,12]. If artificial nutrition is
administered, clear patient-centered goals and time frames for evaluation need to be decided upon. References [1] WHO. WHO definition of palliative care. Available at: http://www.who.int/ cancer/palliative/definition/en/. Accessed May 4, 2012. [2] Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, et al. Definition and classification of cancer cachexia: An international consensus. Lancet Oncol 2011;12:489–95. [3] Oberholzer R, Blum D, Strasser F. The concept of cachexia-related suffering (CRS) in palliative cancer care. In: Preedy VR, editor. Diet and nutrition in palliative care. CPC Press; 2011. p. 245–55. [4] Maillet J. Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc 2008;108: 873–82. [5] Hopkinson JB. The emotional aspects of cancer anorexia. Curr Opin Support Palliat Care 2010;4:254–8. [6] van der Riet P, Good P, Higgins I, Sneesby L. Palliative care professionals’ perception of nutrition and hydration at the end of life. Int J Palliat Nurs 2008;14:145–51. [7] Ellershaw J, Wilkinson S. Care of the dying: A pathway to excellence. 2nd ed. Oxford: University Press; 2011. [8] Shragge JE, Wismer WV, Olson KL, Baracos VE. Shifting to conscious control: Psychosocial and dietary management of anorexia by patients with advanced cancer. Panminerva Med 2007;21:227–33. [9] Niedert KC. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc 2005;105:1955–65. [10] Darmon P, Kaiser MJ, Bauer JM, Sieber CC, Pichard C. Restrictive diets in the elderly: Never say never again? Clin Nutr 2010;29:170–4. [11] Good P, Cavenagh J, Mather M, Ravenscroft P. Medically assisted nutrition for palliative care in adult patients. Cochrane Database Syst Rev 2008;4:CD006274. [12] Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011;22:1478–86.
