Nutritional Management in Palliative Care

1 ESPEN 2003. For personal use Congress Cannes2003 Organised by the Israel Society for ClinicalNutritionSession: Nutrition and Palliative CareNutritional ManagementProfessor Luiza Kent-SmithPorto, and Clinical Practice ProgrammeNutritional ManagementNutritional Managementin Palliative Carein Palliative CareLuiza Kent-Smith - Faculty of Nutrition, Univ. of Porto - Luiza Kent-Smith - Faculty of Nutrition, Univ. of Porto - who is among the livinghas hope ..Ecclesiastes 9:4 ESPEN 2003. For personal use Question ?Question ?Is Nutrition SupportIs Nutrition Supportneeded / justifiedneeded / justifiedin Palliative care ???in Palliative care ???Presentation OutlinePresentation OutlinennPalliative CarePalliative care Definition (WHO 2002)Definition (WHO 2002) PrinciplesPrinciplesnnNutrition in Palliative careNutrition in Palliative care What changes?What changes?

2 EAPC guidelinesEAPC guidelines Nutrition support optionsNutrition support options ESPEN 2003. For personal use the total care of patients whoseIs the total care of patients whoseconditions do not respond to curativeconditions do not respond to - to promote the best possibleGoal - to promote the best possibleQOL for patients and their familiesQOL for patients and their familiesPalliative care :(WHO 2002)WHO states that WHO states that Palliative CarePalliative care ::nnAffirms life and regards dying as a normalAffirms life and regards dying as a normalprocess;process;nnNeither hastens nor postpones death;Neither hastens nor postpones death;nnProvides relief from pain and otherProvides relief from pain and otherdistressing symptoms. ESPEN 2003. For personal use CarePalliative CarennPhysical carePhysical carennSymptom managementSymptom managementnnPsychosocial & spiritual carePsychosocial & spiritual carennMultidisciplinary teamMultidisciplinary teamnnPatient & family Patient & family FF care decisions care decisions(WHO 2002)What Changes in Palliative care ?

3 What Changes in Palliative care ?The aims of Nutritional support change withThe aims of Nutritional support change withdisease must receive food/nutrition but thePatients must receive food/nutrition but theemphasis is onemphasis is on QOL and symptom reliefQOL and symptom reliefrather than active Nutritional than active Nutritional therapy. ESPEN 2003. For personal use approachSolutionsConstant follow-up Palliative Nutrition Support(Power, 1999)Nutrition Support in Palliative care ?Nutrition Support in Palliative care ?Health care Team Perspective:Health care Team Perspective: Clinical, ethical & moral dilemasClinical, ethical & moral dilemas Doubts & uncertaintiesDoubts & uncertainties Different opinionsDifferent opinions Lack of a systematic approachLack of a systematic approach Need for trained professionalsNeed for trained professionals ESPEN 2003.

4 For personal use Support in Palliative care ?Nutrition Support in Palliative care ?nnDisease progressionDisease progressionnnSymptomsSymptomsnnProgressi ve Nutritional deteriorationProgressive Nutritional deterioration Weight lossWeight loss Changes in body imageChanges in body imagennAltered food intakeAltered food intakennThe meaning of The meaning of FoodFood Patient s Perspective:The meaning of The meaning of FoodFood Food can serve many needs:Food can serve many needs:Food is life44 PhysicalPhysical44 Comfort/ nurtureComfort/ nurture44 Tradition/ cultureTradition/ culture44 SocializationSocialization44 PsychologicalPsychological ESPEN 2003. For personal use advanced diseaseIn advanced disease Hope Hope Confort Confort Pleasure Pleasure+ Guilt Fear Pain-Food means:(Gallagher, 1989)nnMaintain/improve QOLM aintain/improve QOLnnControl symptomsControl symptomsNutrition SupportOverall Objective:Overall Objective: Palliative care ESPEN 2003.

5 For personal use Palliative Nutrition SupportGuidelines Palliative Nutrition Support Clinical assessment Oncological staging Symptoms Nutritional assessment Psychological attitude Food intake FunctionDECISIONS pecialneeds Survival: Short Medium Long(EAPC, 1996) Nutritional AssessmentNutritional AssessmentnnAdvanced Advanced metastaticmetastatic cancer (n=352) cancer (n=352)nnNo single measurement is adequate!No single measurement is adequate! CRP CRP increased in 74% increased in 74% Severe fat deficiency by TSF in 51%Severe fat deficiency by TSF in 51% High muscle mass loss by AMA in 30%High muscle mass loss by AMA in 30% BMI BMI normal or increased normal or increased Wt loss in 87% Wt loss in 87% (( 10% Wt loss 10% Wt loss in 71%)in 71%) Anorexia in 81%Anorexia in 81% Early satiety in 69%Early satiety in 69%nnBioimpedanceBioimpedance (body composition & BCM)(body composition & BCM)(Sarhill et al, 2003) ESPEN 2003.

6 For personal use Assessment ToolsValidated Assessment ToolsnnEdmonton Symptom Assessment ScaleEdmonton Symptom Assessment ScalennSymptom Distress ScaleSymptom Distress ScalennPalliative Performance ScalePalliative Performance ScalennQLQ QLQ C30 (EORTC) C30 (EORTC)nnSupport Team AssessmentSupport Team AssessmentnnSymptom Distress ScaleSymptom Distress Support OptionsNutrition Support OptionsHydrationHydrationOral SupplementsEnteral NutritionEnteral NutritionOral FeedingConfortFoodsParenteral NutritionParenteral Nutrition ESPEN 2003. For personal use Long as Food = PleasureOral FeedingOral FeedingnnIndividual preferencesIndividual preferencesnn la carte la carte meals mealsnnAppealing presentationAppealing presentationnnPersonalized portionsPersonalized portionsnnAdapted consistencyAdapted consistencynnDiet counsellingDiet counsellingnnFlexible timetablesFlexible timetablesnnAgreeable environmentAgreeable environmentnnFamily involvementFamily involvementnnStaff participationStaff participationPractical ApproachPractical ApproachRe-think and adapt hospital feeding routines(Gallagher, 1989)(ADA 1997) ESPEN 2003.

7 For personal use to EatingBarriers to EatingnnDifficulty chewing /Difficulty chewing /swallowingswallowingnnNausea / vomitingNausea / vomitingnnAnorexia / early satietyAnorexia / early satietynnOverwhelmed by portionOverwhelmed by portionsizesizennXerostomiaXerostomiannT aste and smell changesTaste and smell changesgg Adapt consistency Adapt consistencygg hh CHO & cool clear liquidsCHO & cool clear liquids Food preferences, small Food preferences, smallfrequent meals, frequent meals, hh Kcal foods Kcal foods& supplements& supplementsgg Chewing gum, sour candy, Chewing gum, sour candy,ice chips, stews, saucesice chips, stews, saucesgg Luke warm bland foods Luke warm bland foodsOral SupplementationOral SupplementationnnAllows for:Allows for: Increased energy intakeIncreased energy intake Increased protein intakeIncreased protein intake(Power, 1999)Frequent bolusReduced volumeEasy ingestion ESPEN 2003.

8 For personal use Nutrition NutritionnnRecommended:Recommended: severe dysphasiasevere dysphasia severe anorexia severe anorexia decreased food intake decreased food intake4 Clinical indications: head & neck / esophagus tumours inoperable fistulae esophageal obstructions(Boyd, 1994)(Boyd, 1994)Enteral NutritionEnteral NutritionnnAdjust:Adjust: delivery methoddelivery method volume volume duration of delivery duration of delivery4 Changes with: disease progression new symptoms interruption (?)(Boyd, 1994) ESPEN 2003. For personal use Nutrition Nutrition4 Selected patients4 Inoperable intestinal obstruction4 Prolonged survival4 Risks vs. Benefits(Torelli, 1999)(Faisinger, 1997)ParenteralParenteral Nutrition NutritionnnLimited Use:Limited Use: IncreasedIncreased c complicationsomplications Difficulties in Home care implementationDifficulties in Home care implementation Cost Cost Ethical Ethical Dilemas Dilemas(Torelli, 1999)(Faisinger, 1997) ESPEN 2003.

9 For personal use Gynaecological CancerAdvanced Gynaecological Cancer (n=(n=33)33)PCUPCU hospitalization hospitalizationnnMotiveMotive Symptom control Symptom control % % Terminal care Terminal care % %nnDurationDuration ( 7 ( 7 98 98 diasdias ) ) mean = 31; median = 19mean = 31; median = 19 discharged discharged deceased deceased(Porto Cancer Centre) Nutritional SupportNutritional Support (n=33)(n=33)nnComfort foods (CF) Comfort foods (CF) 50% 50%nnCF + Oral supplements (OS)CF + Oral supplements (OS) Residue Diets + OS Low Residue Diets + OS 10% 10%nnClear liquids Clear liquids nutrition + CF Parenteral nutrition + CF - ?Hydration - ?NS 78%, 40 interventions = (Porto Cancer Centre) ESPEN 2003. For personal use (against)(against)nnComatose patients donComatose patients don t experience thirstt experience thirstnnHydration may prolong deathHydration may prolong deathnnDecreased Decreased diuresisdiuresis less mobilization less mobilizationnnDehydrationDehydration - - ii consciousness consciousness ii sufferingsufferingnnii GIGI secretions - secretions - ii vomitingvomitingnnii Lung secretions - Lung secretions - ii coughingcoughingnnii Oedema - Oedema - ii ascitesascitesMacDonald & Faisinger 1996 HydrationHydration (in favour)(in favour)

10 Nnhh patient comfort patient comfortnnNo evidence that prolongs deathNo evidence that prolongs deathnnDehydration Dehydration delirium & renal failure delirium & renal failurennGood inGood in opioid opioid toxicity delirium toxicity deliriumnnGood inGood in hypercalcemia hypercalcemiaMacDonald & Faisinger 1996 ESPEN 2003. For personal use 1st approachHydration 1st approachnnKeeping mouth wetKeeping mouth wetnnKeeping lips lubricatedKeeping lips lubricatednnGood oral careGood oral carennSmall sips of liquidsSmall sips of liquidsnnSucking iced water or fruitSucking iced water or fruitDecrease thirst by:Hydration MethodsHydration MethodsnnEnteralEnteral route routennParenteralParenteral route route peripheralperipheral centralcentralnnSubcutaneous route (Subcutaneous route (hypodermoclysishypodermoclysis))(Fainsi nger & Bruera 1994) ESPEN 2003. For personal use HydrationSubcutaneous HydrationnnEasier accessEasier accessnnEasier & safer home useEasier & safer home usennSubcutaneous sites last up to 7 daysSubcutaneous sites last up to 7 daysnnEasily turned off and disconnectedEasily turned off and disconnectednnFacilitates mobilityFacilitates mobilityFainsinger et al.