Nutritional Support and Hydration for Patients near the End-of-Life

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• May artificial feedings/hydration be withdrawn?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 110734, 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 20225, 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
  112043,1993.

16
Enteral Nutritional Support-Tube

• Gastrostomy vs. NG-tube
• of prescribed intake
• G-tube 93 NG-tube 55 (p lt 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
  3041406, 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 148429-433.

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 lt 0.01)
• Scott AG, Austin HE Nasogastric feeding in the
  mangement of severe dysphagia in motor neurone
  disease. Pall Med 845, 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 86169, 1993.

20
Tube Feeding in Patients with DementiaA 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 2821365, 1999.

21
Tube Feeding in Patients with DementiaA 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 gt 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 2821365, 1999.

22
Pharmacologic Interventions

• 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 2721263, 1994.

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 94767, 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 94767, 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.

32
Studies on Symptoms of Dehydration

• Collaud et al J Pain Symp Manag, 6230, 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 311753, 1984
• Elderly experience reduced thirst after water
  deprivation when compared to young
• Burge J Pain Symp Manag 8454, 1993
• VAS assessment of symptoms of dehydration
• Pleasure in drinking 70/100 (avg) 40-80 (range)
  
• Fatigue 70/100 40-90 Dry mouth 55/100 50-90
• Bad taste 50 15-75 Thirst 50 30-80

33
Hydration near the End-of-Life

• Adapted from Rousseau P How fluid deprivation
  affects the terminally ill. RN54, 73, 1991.

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 1287, 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 2721263, 1994.

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.