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Nutrition, Eating, and Palliative Care Ted St. Godard MA MD.

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Presentation on theme: "Nutrition, Eating, and Palliative Care Ted St. Godard MA MD."— Presentation transcript:

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2 Nutrition, Eating, and Palliative Care Ted St. Godard MA MD

3 Let food be your medicine and let medicine be your food. Hippocrates Sex is good, but not as good as fresh, sweet corn. Sex is good, but not as good as fresh, sweet corn. Garrison Keillor

4 I. Psycho-social aspects of eating and not eating starving, wasting, some patients starving, wasting, some patients II. Approach to patients and families III. Nutrition challenges in the gravely ill IV. Cachexia versus Starvation (? Decreased PO = starvation) V. Role for Artificial Nutrition Yes, no, maybe so? Yes, no, maybe so? VI. Palliative Perspective

5 Nothing would be more tiresome than eating and drinking if [they were not] a pleasure as well as a necessity. Voltaire

6 Meals/eating highly loaded Meals/eating highly loaded celebrations, milestones, happy times, sad times, memories celebrations, milestones, happy times, sad times, memories Many or most patients with terminal illness ultimately are unable to eat enough to avoid weight loss and maintain activity levels Many or most patients with terminal illness ultimately are unable to eat enough to avoid weight loss and maintain activity levels

7 Patients Patients Body image? Sexuality? Body image? Sexuality? Embarrassment, shame, guilt, frustration Embarrassment, shame, guilt, frustration Weaker and weaker, smaller and smaller Weaker and weaker, smaller and smaller Im wasting away… Im wasting away…

8 Families Families Frustration, anger Frustration, anger LO weaker, smaller, frailer, but wont eat LO weaker, smaller, frailer, but wont eat Try harder, vicious circle Try harder, vicious circle Conflict Conflict We cant just let her/him starve… We cant just let her/him starve…

9 Starvation Starvation We live in a world where this ought not to happen We live in a world where this ought not to happen Unconscionable Unconscionable Wasting Wasting Inefficient, shameful, immoral? Inefficient, shameful, immoral?

10 Nutrition is a basic animal need Nutrition is a basic animal need Is feeding a fundamental component of care? A right? Is feeding a fundamental component of care? A right?

11 38 male, metastatic esophageal Ca. 38 male, metastatic esophageal Ca. Presented with pneumo-mediastinum Presented with pneumo-mediastinum PEG PEG Cachectic, ate (copiously) for months Cachectic, ate (copiously) for months 53 female, metastatic ovarian Ca., bowel obstruction 53 female, metastatic ovarian Ca., bowel obstruction Obese, eating (copiously) around NG Obese, eating (copiously) around NG Increasing emesis… How will we feed her now? Increasing emesis… How will we feed her now?

12 73 male, metastatic hepato-cellular Ca., 73 male, metastatic hepato-cellular Ca., Frail, bedbound, cachectic, icteric Frail, bedbound, cachectic, icteric Doctor, he no eat. Make him eat Doctor, he no eat. Make him eat 53 female, metastatic breast Ca., bowel obstruction (multiple omental mets, abd/pelvic adenopathy) 53 female, metastatic breast Ca., bowel obstruction (multiple omental mets, abd/pelvic adenopathy) Looks well, ambulating Looks well, ambulating So now I just starve to death? So now I just starve to death?

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14 Goals of Care (Maintain quality of life; avoid prolongation of dying)

15 WHO definition: WHO definition: Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

16 WHO definition: WHO definition: …improves quality of life of patients and their families …improves quality of life of patients and their families ……prevention and relief of suffering ……prevention and relief of suffering …..early identification,… assessment and treatment of …..early identification,… assessment and treatment of …. problems, physical, psychosocial and spiritual. …. problems, physical, psychosocial and spiritual.

17 Active Treatment Palliative Care

18 Active Treatment Palliative Care

19 Cure, restore function, prolong life, provide comfort Cure, restore function, prolong life, provide comfort

20 Comfort always Prolong life Restore function Cure

21 Failure to achieve balance Failure to achieve balance 1. Decreased PO intake Anorexia, xerostomia, altered taste/smell, odyno/dysphagia Anorexia, xerostomia, altered taste/smell, odyno/dysphagia 2. Decreased absorption 3. Altered energy utilization

22 Inadequate ingestion Developed countries: medical reasons Developed countries: medical reasons Worldwide: lack of food Worldwide: lack of food

23 Anorexia (loss of appetite) Anorexia (loss of appetite) Multi-factorial Multi-factorial Cytokines: central (hypothalamic) and peripheral (via vagus nerve) influences Cytokines: central (hypothalamic) and peripheral (via vagus nerve) influences Huge frustration for families, source of much tension Huge frustration for families, source of much tension

24 AnorexigenicNeuropeptide Neurotensin Melanocortin CRF OrexigenicNeuropeptide Glucogon CCKLeptin Blood Brain Barrier NPY AGRP MCHNeurotensin Melanocortin CRF Glucogon CCKLeptin NPY AGRP MCH CNS Cytokinase Cytokinase CNTF IL-1 CNTF IL-1 Food Intake Energy Expenditure Food Intake Energy Expenditure Seratonin Blood Brain Barrier IL-6 Tryptophan Glucocorticoids ACTH AnorexigenicNeuropeptide OrexigenicNeuropeptide IL-1IL-6 TNF- TNF- INF- INF- _ _ _ _ _ _ _ _ _ A B

25 Approach: Approach: 1. Symptom control (nausea, pain) 2. Meal selection, timing, portion/presentation 3. Avoid/reduce conflict (eat, drink, be merry): eat what, where, when, as much/little as you want

26 Progestational agents: Megestrol Progestational agents: Megestrol Corticosteroids: Dexamethasone Corticosteroids: Dexamethasone

27 ?Metoclopromide ?Metoclopromide ?Cannabinoids ?Cannabinoids ?Melatonin (decrease TNF) ?Melatonin (decrease TNF) ?NSAIDS (decrease inflammatory mediators) ?NSAIDS (decrease inflammatory mediators)

28 Appetite stimulants may increase intake, body weight, and quality of life, but they do not affect prognosis in the terminally ill Dy, M. Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: a Review of the Literature. American Journal of Hospice and Palliative Medicine. 2006; 23 (5):

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30 Nausea Nausea Emesis Emesis Diarrhea Diarrhea Surgical/anatomical changes Surgical/anatomical changes 3. Altered energy metabolism

31 Thomas, D. Distinguishing Starvation from Cachexia. Clinics in Geriatric Medicine. 2002; 18: Starvation: pure protein/energy deficiency (under-nutrition) Starvation: pure protein/energy deficiency (under-nutrition) Cachexia: cytokine-induced wasting of protein and energy stores, caused by effects of disease Cachexia: cytokine-induced wasting of protein and energy stores, caused by effects of disease Malignancy, COPD, ESRD, CHF, AIDS, RA Malignancy, COPD, ESRD, CHF, AIDS, RA Remarkably resistant to hyper-caloric feeding Remarkably resistant to hyper-caloric feeding

32 Thomas, D. Distinguishing Starvation from Cachexia. Clinics in Geriatric Medicine. 2002; 18: Biochemical markers represent nutritional status or illness severity? Biochemical markers represent nutritional status or illness severity? Acute-phase cytokine response Acute-phase cytokine response Strong inverse correlation between IL-2R and albumin, pre-albumin, cholesterol, Hgb Strong inverse correlation between IL-2R and albumin, pre-albumin, cholesterol, Hgb Common pathway to reduction in albumin, etc. may be cytokine induction, rather than absence of nutrients Common pathway to reduction in albumin, etc. may be cytokine induction, rather than absence of nutrients

33 StarvationCachexia AppetiteLate suppressionEarly suppression BMINot predictive of mortalityPredictive of mortality AlbuminLow in late phaseLow in early phase CholesterolMay remain normalLow Total lymphocyte count Low, responds to re-feeding Low, no response to re-feeding CytokinesLittle dataElevated InflammationUsually absentPresent With re-feedingReversibleResistant Thomas, D. Distinguishing Starvation from Cachexia. Clinics in Geriatric Medicine. 2002; 18:

34 Ethical Principles Ethical Principles Autonomy Autonomy Beneficence Beneficence Non-maleficence Non-maleficence Informed consent Informed consent Beauchamp and Childress. Principles of Biomedical Ethics. New York: Oxford University Press (4 th Ed.)

35 Informed consent. Patient/surrogate: Informed consent. Patient/surrogate: Is able to communicate consistent preference Is able to communicate consistent preference Understands risks, benefits, and alternatives Understands risks, benefits, and alternatives Appreciates the information Appreciates the information Uses rational thinking to arrive at decision Uses rational thinking to arrive at decision Beauchamp and Childress. Principles of Biomedical Ethics. New York: Oxford University Press (4 th Ed.)

36 Nutrition is a basic animal need Nutrition is a basic animal need Is feeding a fundamental component of care? A right? Is feeding a fundamental component of care? A right?

37 Artificial, specialized nutritional support is no different from any other life sustaining medical therapy that supports bodily function, such as antibiotics, oxygen therapy, or dialysis. Artificial, specialized nutritional support is no different from any other life sustaining medical therapy that supports bodily function, such as antibiotics, oxygen therapy, or dialysis. Not offering it is ethically acceptable if benefits do not outweigh the risks for a particular individual. Not offering it is ethically acceptable if benefits do not outweigh the risks for a particular individual. McClave, S., Ritchie, C. The Role of Endoscopically Placed Feeding or Decompression Tubes. Gasteroenterology Clinics of North America. 2006; 35:

38 There is no ethical or legal difference between withholding a … feeding tube versus placing the feeding tube and then later removing it There is no ethical or legal difference between withholding a … feeding tube versus placing the feeding tube and then later removing it Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

39 Several Groups of Potential Beneficiaries Several Groups of Potential Beneficiaries 1. Malignant disease 2. Acute CVA 3. Dementia 4. Neurodegenerative diseases

40 Two Potential Benefits Two Potential Benefits 1. Prolong life 2. Palliate: improve comfort, enhance quality of life (for patients and their care-givers/loved ones)

41 1. Patients with Malignancies Despite increased nutrient delivery, trials show disappointing results in improving clinical outcome Despite increased nutrient delivery, trials show disappointing results in improving clinical outcome Improvements in biochemical markers inconsistently correlate with objective clinical benefits Improvements in biochemical markers inconsistently correlate with objective clinical benefits Thomas, D. Distinguishing Starvation from Cachexia. Clinics in Geriatric Medicine. 2002; 18:

42 1. Patients with Malignancies ?survival benefit if PEG in early head and neck cancers (tolerate treatments better) ?survival benefit if PEG in early head and neck cancers (tolerate treatments better) Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

43 Dy, M. Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: a Review of the Literature. American Journal of Hospice and Palliative Medicine. 2006; 23 (5): Patients with Malignancies Little evidence was found for benefits from enteral or parenteral nutrition in terminally ill cancer patients, other than for those with mechanical gastrointestinal tract obstruction Little evidence was found for benefits from enteral or parenteral nutrition in terminally ill cancer patients, other than for those with mechanical gastrointestinal tract obstruction

44 Hunger Hunger Often not noted Often not noted Ameliorated usually with small amounts food/drink Ameliorated usually with small amounts food/drink Dy, M. Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: a Review of the Literature. American Journal of Hospice and Palliative Medicine. 2006; 23 (5):

45 2. Acute CVA with Dysphagia Survival Survival Morbidity Morbidity Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

46 2. Acute CVA with Dysphagia RCT compared tube feeds within 7 days of admission versus no tube feeding for more than 7 days RCT compared tube feeds within 7 days of admission versus no tube feeding for more than 7 days Early tube feeding associated with NS reduction in risk of death (ARR 5.8 %) Early tube feeding associated with NS reduction in risk of death (ARR 5.8 %) Survival ? offset by 4.7 % excess of survivors who had poorer outcomes Survival ? offset by 4.7 % excess of survivors who had poorer outcomes Dennis, Lewis, Warlow, C. Effect of Timing and Method of Enteral Tube Feeding for Dysphagic Stroke Patients. Lancet. 2005; 26 (365):

47 3. Dementia 34 % pts. with dementia or cognitive impairment have PEGs 34 % pts. with dementia or cognitive impairment have PEGs Prevent aspiration, heal/preven skin ulcers, prolong life Prevent aspiration, heal/preven skin ulcers, prolong life Evidence equivocal at best on all counts Evidence equivocal at best on all counts McClave, S., Ritchie, C. The Role of Endoscopically Placed Feeding or Decompression Tubes. Gasteroenterology Clinics of North America. 2006; 35:

48 3. Dementia Patients with dementia who are so disabled as to stop eating have poor prognosis even with PEG Patients with dementia who are so disabled as to stop eating have poor prognosis even with PEG PEG in demented patients huge risk factor for restraints PEG in demented patients huge risk factor for restraints Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

49 4. Neurodegenerative disease ALS ALS Cognition usually spared Cognition usually spared 10 – 20 % 5-year survival without artificial ventilation and nutrition 10 – 20 % 5-year survival without artificial ventilation and nutrition With support, lifespan can be extended indefinitely With support, lifespan can be extended indefinitely Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

50 4. Neurodegenerative disease PEG in ALS PEG in ALS Improves nutrition Improves nutrition Makes eating easier (lessens fatigue) Makes eating easier (lessens fatigue) Decreases time spent feeding Decreases time spent feeding Allays fears of choking Allays fears of choking ? Improved QOL ? Improved QOL Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

51 4. Neurodegenerative disease PEG in ALS PEG in ALS Mortality benefit? Mortality benefit? Survival increased only in patients where PEG inserted early Survival increased only in patients where PEG inserted early FVC < 50 % predicted increases risk mortality FVC < 50 % predicted increases risk mortality Ganzini, L. Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence. Palliative and Supportive Care. 2006; 4:

52 Several Groups of Potential Beneficiaries Several Groups of Potential Beneficiaries 1. Malignant disease 2. Acute CVA 3. Dementia 4. Neurodegenerative diseases Two Potential Benefits Two Potential Benefits 1. Prolong life 2. Palliate: improve comfort, enhance quality of life (for patients and their care-givers/loved ones)

53 Issues surrounding eating and nutrition come to play a very significant role in the lives of people with most end stage illnesses Issues surrounding eating and nutrition come to play a very significant role in the lives of people with most end stage illnesses Often more difficult for families than patients Often more difficult for families than patients Potential source of much conflict Potential source of much conflict

54 Decreased PO intake, and altered ability to metabolize nutrients effectively is etiologically complex Decreased PO intake, and altered ability to metabolize nutrients effectively is etiologically complex Depending on goals of care, there sometimes is a role for medication and/or artificial nutrition Depending on goals of care, there sometimes is a role for medication and/or artificial nutrition Treatment must always and everywhere take into considerations of goals of care Treatment must always and everywhere take into considerations of goals of care

55 Edible: Good to eat and wholesome to digest; as a worm to a toad, a toad to a snake, a snake to a pig, a pig to a man, and a man to a worm. Ambrose Bierce Edible: Good to eat and wholesome to digest; as a worm to a toad, a toad to a snake, a snake to a pig, a pig to a man, and a man to a worm. Ambrose Bierce


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