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Nutritional Support and Hydration for Patients near the End-of-Life Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Innovative Hospice Care Miami,

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Presentation on theme: "Nutritional Support and Hydration for Patients near the End-of-Life Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Innovative Hospice Care Miami,"— Presentation transcript:

1 Nutritional Support and Hydration for Patients near the End-of-Life Barry M. Kinzbrunner, MD Chief Medical Officer Vitas Innovative Hospice Care Miami, FL

2 Objectives Review the pathophysiological mechanisms that result in an altered nutritional status and altered hydration as patients near the end-of-life. Summarize the data in the medical literature regarding nutritional support and hydrational support for patients near the end-of-life. Examine how the cardinal ethical values impact decision-making regarding nutritional support and hydration at the end-of-life.

3 Nutrition & Hydration: Ethical Questions Do patients/families have a right to demand or refuse artificial food/fluid? May artificial feedings/hydration be withheld? May artificial feedings/hydration be withdrawn? May health care facilities deny care based on a patient/family decision regarding artificial nutrition/hydration?

4 Nutrition & Hydration: Autonomy Patients/families have a right to choose whether or not to receive artificial nutrition or hydration –Social reasons –Religious reasons Health care providers and facilities have a right to set policies as to whether they want to care for patients who decline artificial feeding/hydration.

5 Nutrition & Hydration: Beneficence Beneficence Belief that artificial nutrition and hydration: Improves nutritional status Reduces aspiration pneumonia risk Assists in healing of decubitus ulcers Improves functional status Reduces hunger and thirst

6 Nutrition & Hydration: Non-Maleficence Non-Maleficence Belief that artificial nutrition and hydration: Reduces aspiration pneumonia risk Is a low risk procedure to the patient Reduces hunger and thirst

7 Nutrition & Hydration: Justice Social Society has an obligation to protect citizens who are unable to take of themselves Society should not deny basic care to individuals based on their mental status or other medical conditions Distributive Ability to provide skilled vs. unskilled care Cost of artificial feeding –Procedure, pump, formula all reimbursable services Spoon feeding with an attendant –Labor intensive which is not reimbursable

8 Nutrition Near the End of Life Cancer anorexia-cachexia syndrome Metabolic Abnormalties –Carbohydrate metabolism Insulin resistance Glucose intolerance –Lipid and protein metabolism Gluconeogenesis from lipid and protein sources Humoral mediators –Tumor necrosis factor –Interleukins –Gamma interferons Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

9 Nutrition Near the End of Life Direct effects of tumors and antineoplastic therapy Abdominal fullness Taste change Dry mouth Constipation Uncontrolled nausea and emesis Dysphagia Mechanical obstruction Uncontrolled Pain Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

10 Nutrition Near the End of Life Anorexia in the debilitated patient Impaired mobility Impaired cognition Modified consistency diets Upper extremity dysfunction Abnormal oral and pharyngeal function Impaired dentition, ill-fitting dentures Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

11 Treatment of Malnutrition Parenteral nutritional support –Total parenteral nutrition (TPN) Enteral nutritional support –Oral supplementation with or without dietary counseling –Gastrointestinal intubation Nasogastric tube Percutaneous endoscopic gastrostomy Operative gastrostomy Pharmacologic interventions Non-Pharmacologic interventions

12 Parenteral Nutritional Support Analysis of 12 prospective randomized trials evaluating the use of TPN in patients receiving chemotherapy Rate of infection: –Increased in TPN patients in 4/6 studies (2 with no difference, 6 did not report) Survival: –Decreased in TPN patients in 2/9 studies (7 with no difference, 3 did not report) Tumor response –No difference in 9/9 studies (3 did not report) Klein, S. Clinical efficacy of nutritional support in patients with cancer. Oncology: 7(11,suppl), 87-92, 1993.

13 Parenteral Nutritional Support American College of Physicians Position Paper Parenteral Nutrition in Patients Receiving Cancer Chemotherapy “…(T)he evidence suggests that parenteral nutrition support was associated with net harm, and no conditions could be defined in which such treatment appeared to be of benefit. Thus, the routine use of parenteral nutrition for patients undergoing chemotherapy should be strongly discouraged….” American College of Physicians. Parenteral Nutrition in Patients Receiving Cancer Chemotherapy. Ann Int Med 110:734, 1989.

14 Enteral Nutritional Support-Oral Terepka and Waterhouse: 1956 Metabolism of force-fed patients with cancer 9 patients with progressive cancer Weight gain secondary to intracellular fluid retention Early retention of nitrogen and phosphorus Subsequent return of negative nitrogen balance Half the patients had detrimental effects from forced feeding Terepka AR, Waterhouse C: Metabolism of force-fed patients with cancer. Am J Med 20:225, 1956.

15 Enteral Nutritional Support-Oral Ovesen et al. Effect of dietary counseling and diet on response to chemotherapy. 1993 Randomized trial Responsive malignancies –Small cell lung caner –Breast cancer –Ovarian cancer No significant response or survival advantage found between group that received dietary counseling and control group. Ovesen L, Allingstrup L., Hannibal J., et al: Effect of dietary counseling on food intake, response rate, survival, and quality of life in cancer patients undergoing chemotherapy. A prospective randomized trial. J Clin Oncol 11:2043,1993.

16 Enteral Nutritional Support-Tube Gastrostomy vs. NG-tube % of prescribed intake –G-tube 93%; NG-tube 55% (p < 0.001) Reasons for failure –G-tube (0/19) –NG-tube (18/19) Failure to position Displacement of tube Patient refusal Park, RH, Allison, BC, Lang, J, et al: Randomized comparison of percutaneous endoscopicgastrostomy and nasogastric tube feeding patients with persisting neurological dysphagia. Br Med J 304:1406, 1992.

17 Enteral Nutritional Support-Tube Efficacy of Tube Feedings. Ciocon JO, Silverstone, FA, Graver LM, Foley CJ: Tube feedings in elderly patinets. indications, benefits, and complications. Arch Int Med 148:429-433.

18 Enteral Nutritional Support-Tube Patients with dysphagia 2° Motor Neuron Disease Tube feeding vs. conservative management No significant difference in age of death or median or mean survival Significant differences in problems with secretions –NG = 13/13 –Conservative mgmt = 8/18 (p < 0.01) Scott AG, Austin HE: Nasogastric feeding in the mangement of severe dysphagia in motor neurone disease. Pall Med 8:45, 1994.

19 Enteral Nutritional Support-Tube Mortality in Gastrostomy Patients Stuart SP, Tiley EH, Boland JP: Feeding gastrostomy: A critical review of its indications and mortality rate. South Med J 86:169, 1993. IndicationMortality Rate% Mortality Neurologic Debilitation19/6728% Head and Neck Cancer2/1612% Metastatic cachexia3/837% Pulmonary cachexia9/1090% Postoperative inanition1/250% Total34/10333%

20 Tube Feeding in Patients with Dementia A Review of the Evidence Review of published evidence regarding benefits of tube feedings: No reduction in aspiration pneumonia risk No effect on clinical markers of nutrition No improvement in patient survival No improvement or prevention of decubitus ulcers No reduction in infection risk No improvement in functional status or slowing of decline No improvement in patient comfort Fincune TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999.

21 Tube Feeding in Patients with Dementia A Review of the Evidence Review of published evidence regarding harmful effects of tube feedings: Mortality –Perioperative mortality 6-24% –30 day mortality 2-27% –1 year mortality > 50% Aspiration 0-66%Local infection 4-16% Occlusion 2-34%Leaking 13-20% 2/3 of NG tubes require replacement Fincune TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999.

22 Pharmacologic Interventions MedicationDosage Steroids Dexamethasone1.5-4 mg qd to qid Methylprednisolone20 mg qd to qid Prednisone20 mg qd to qid Megestrol acetate160-400 mg bid Metoclopramide10 mg tid ac and hs Tetrohydrocannibinol (THC)2.5 mg tid Cyproheptidine4 mg tid Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

23 Pharmacologic Interventions Steroids Improve appetite in 50-75% of patients with cancer Effects within days Maximum effect within 4 weeks Effects fade over time Side effects –Oral thrush –Edema and cushingoid features –Dyspepsia –Psychic changes –Ecchymoses Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

24 Pharmacologic Interventions Megestrol Acetate Effects on appetite and food intake Less clear effect on body weight Possible improvement in quality of life Minimum effective dose 160 mg/day Maximum effective dose 800 mg/day Requires minimum of 2-3 months for effect Should not be started on patients with prognoses of several weeks or less Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

25 Pharmacologic Interventions Metoclopramide Increases lower esophageal sphincter pressure Effective for symptoms related to delayed gastric empyting Will cause increase in symptoms in patients with gastric outlet obstruction Extrapyramidal side effects –Reversed with benedryl Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

26 Pharmacologic Interventions Tetrahydrocannibinol Primarily studied in HIV patients Stimulation of appetite and mood, some weight gain 2.5 mg tid CNS toxicity (especially in elderly) –Dizziness –Somnolence –Dissassociation Cyproheptadine Borderline appetite stimulation compared to placebo No weight gain Increased somnolence and dizziness Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

27 Non-pharmacologic Interventions Assess for treatable causes –Oral thrush –Nausea and emesis –Metabolic disturbances Dietary counseling to adjust eating habits –Smaller plates and portions –Eat whenever desired –Lift dietary restrictions (i.e. low salt, ADA) –Allow favorite foods –Avoid strong smells, spices, hot foods Dietary counseling to explain changing dietary needs to patient and family –Need for less food –Lifting of dietary restrictions Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

28 Studies on Hunger at the End-of-Life 32 patients, according to recorded food and water ingestion McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. J Am Med Assoc 272:1263, 1994. Degree of Hunger # pts (%)Normal intake Reduced intake Liquids only None20 (63%)0182 Present initially 11 (34%)083 Present until death 1 (3%)100 Total32 (100%)1265

29 Studies on Hunger at the End-of-Life Modification of nutritional behavior 116 elderly patients with terminal cancer Patient food preferences Patient dislikes Subjective intolerance to certain foods Difficulties chewing or swallowing Feuz A, Rapin CH: An observational study of the role of pain control and food adaptation of elderly patients with terminal cancer. J Am Dietetic Assoc 94:767, 1994.

30 Studies on Hunger at the End-of-Life Modification of nutritional behavior Results: 107 patients (92%) had meals until the day of death 9 patients (8%) stopped eating an average of 3.5 days before death 51 patients (44%) remained on the diet plan established at first visit Feuz A, Rapin CH: An observational study of the role of pain control and food adaptation of elderly patients with terminal cancer. J Am Dietetic Assoc 94:767, 1994.

31 Hydration Near the End of Life Symptoms of Dehydration Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313. SymptomOccurrenceTreatment ThirstCommonOral fluid, ice chips Dry mouthCommonMeticulous mouth care Artificial saliva Nausea & emesisRareSymptomatic Rx HeadacheNot reported CrampsNot reported Postural hypotensionOccasionalParenteral hydration may be indicated LethargyCommon but w/o distress in bedbound pts May protect against pain and other discomforting symptoms in bedbound pts Drowsiness Fatigue

32 Studies on Symptoms of Dehydration Collaud et al: J Pain Symp Manag, 6:230, 1991 –Physician assessment of importance of symptoms of dehydration Dryness of mouth: 88% serious Thirst: 40% serious Overall suffering: 38% serious Phillips et al: N Eng J Med 311:753, 1984 –Elderly experience reduced thirst after water deprivation when compared to young Burge: J Pain Symp Manag 8:454, 1993 –VAS assessment of symptoms of dehydration –Pleasure in drinking: 70/100 (avg); 40-80 (range) –Fatigue: 70/100; 40-90Dry mouth: 55/100; 50-90 –Bad taste: 50; 15-75Thirst: 50; 30-80

33 Hydration near the End-of-Life Adapted from Rousseau P: How fluid deprivation affects the terminally ill. RN:54, 73, 1991. Organ SystemEffect of Hydration RenalIncreased urinary output Increased need for catheter Increased infection risk PulmonaryIncreased pharygeal & lung secretions Increased dyspnea, cough, congestion Increased risk of pulmonary edema Gastrointestinal tractIncreased GI fluid output Increased risk of nausea & emesis Other body compartments Increased per-tumor edema Increased peripheral edema

34 Hydration near the End-of-Life Common Methods of Delivery of Fluids Intravenous –Peripheral IV –Central access port when available Hypodermoclysis –Subcutaneous infusion –24-25 gauge Teflon catheter –Approximately 1 liter/day maximum –Hyaluronidase 150 units/l Enzyme that breaks down interstitial barriers in subcutaneous space Promotes fluid absorption Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

35 Hypodermoclysis Symptom-related medications that can be administered via this route Pain –Morphine –Hydromorphone Sedation and other CNS symptoms –Midazolam –Haloperidol –Phenobarbital –Dexamethasone Gastrointestinal –Metoclopramide Respiratory secretions –Atropine –scopolamine Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

36 Hypodermoclysis Potential indications for hypodermoclysis in patients near the end-of-life Poor oral pain control Dysphagia Severe emesis Bowel obstruction Confusion Requirement for parenteral medication Cultural or religious need Bruera E, Brenneis C, Michaud M, et al: Use of the subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer 62: 407, 1988.

37 Studies on Hydration at the End-of-Life Bruera et al: J Pain Symp Manag 1:287, 1995 –Relief of delirium Waller et al: Am J Hosp Pall Care: 11(4), 26, 1994 –No difference in level of consciousness between patients who did and did not receive parenteral hydration

38 Symptoms of Thirst at the End-of-Life 32 patients, according to recorded food and water ingestion McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. J Am Med Assoc 272:1263, 1994. Degree of Thirst/Dry mouth # pts (%)Normal intake Reduced intake Liquids only None11 (34%)083 Present initially 9 (28%)090 Present until death 12 (38%)192 Total32 (100%)1265

39 Conclusions Principles for providing Nutritional support and Hydration for patients near the end-of-life Individualize decision making based on the “Principles of Medical Ethics” Consider correctable causes of decreased oral intake and provide appropriate interventions when indicated Prioritize to non-invasive followed by least invasive methods of delivery Tailor amount of food and fluid in such a way as to minimize side effects and toxicities Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.


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