Artificial feeding

1
Artificial feeding venting gastrostomy in
palliative patients

• Dr Nicholas Herodotou
• Macmillan Consultant Palliative Medicine
• LD University Hospital, Luton/S. Beds Community,
  Keech Hospice

2
Topics

• Case reports Palliative Venting Gastrostomy
  (PVG) Artificial Nutrition (AN)
• Ethics Evidence
• Development of a hospital pathway for AN
  Venting PEG

3
Artificial feeding in terminally ill cancer
patients with bowel obstructionNicholas
Herodotou. European Journal of Palliative Care,
2012 19(5)
4
Case 1

• 42 year female, married, 1 adult son
• Peritoneal carcinomatosis Sept 2010
• Carboplatin 6 cycles (Ended Dec 2010)
• Worsening disease Aug 2011
• 2nd course carboplatin (ended Jan 2012)

5
Background

• Two hospital admissions for vomiting
  constipation during Aug-Dec 2011
• Admitted to Milton Keynes hospital March 2012
  diagnosed small bowel obstruction
• Persistent vomiting since Christmas 2011, not
  controlled by syringe driver
• Previous admission to hospice
• Not eaten-except for some milk

6
PMH

• Appendectomy 1996
• peritoneal adhesions 2000
• TAH, BSO for adhesions 2003

7
Medication used in CSCI

• Morphine 100mg
• Haloperidol 3mg
• Buscopan 100mg
• Ondansetron SC PRN
• Had used
• Maxalon
• Cyclizine
• Nozinan SC (made her drowsy)

8
How I got involved?

• Lecture to district nurses on venting PEG
• District Nurse mentioned her patient
• I agreed to review her via her GP
• Admitted to LD 29 March 2012

9
Management

• Didnt appear to be in dying phase
• Started dexamethasone IV 12mg Losec
• Switched morphine to Fentanyl 50mcg
• Switched CSCI to
• Midazolam 5mg
• Octreotide 600mcg
• Nozinan 6.25mg

10
Management

• Enemas
• IV fluids over weekend
• Review after weekend if still vomiting then
  Venting PEG and PEG feeding regime

11
Reviewed after weekend

• Ate for first time for weeks, but next day
  vomiting returned
• Colicky pain, buscopan restarted
• Looked more poorly
• Not suitable for TPN feeding as prognosis less
  than 2 months
• Agreed to Venting PEG artificial feeding via
  PEG

12

• Surgeon vented patient on 3 April
• Ate toast and oral food for first time!
• Dietician advised trying high calorie drinks via
  PEG clamping to allow absorption
• Stopped octreotide, nozinan steroids

13
Outcome

• Discharged home on 6 April
• Kept on CSCI with midaz buscopan
• Added in voltarol via PEG for pain relief
• Patient died at home peacefully 15 April, 12 days
  after procedure
• GP DN said family patient felt it made a big
  difference to her quality of life

14
Case 2

• 32 yr male Irish traveller, married, fifth baby
  due shortly
• Admitted to the LD with abdominal pain
• Diagnosed advanced inoperable colon cancer, with
  small bowel obstruction
• Profuse vomiting
• IV fluids for days

15

• Prognosis about 2 months given
• Some mobility wanted to see baby born
• Advise sought if AN appropriate
• Patient agreed IV feeding commenced
• ?suitability for Home Parenteral Nutrition (HPN)

16

• Nutrition Team secured funding from PCT for home
  parenteral nutrition (HPN)-private service
• Logistics of follow up as mobile caravan
• Survived 4 months and saw his baby born

17
What is a venting PEG?
18
Venting PEG has a wider bore tube 18-25F (feeding
is12F)
19
Types of artificial feeding

• Gastrostomy PEG, RIG, SIG
• JenunostomyPEJ, PEGJ, FNJ
• Parenteral route via Hickman or IV
• Nasogastric tube (NGT)

20
Routes for enteral feeding
21
(No Transcript)
22
Ethics Evidence

• Autonomy
• Beneficence
• Non-maleficence
• Justice

23
Legal issues

• Tony Bland case (1993 House of Lords ruling)
• Mental Capacity Act 2005
• GMC guidance (End of Life Care AN)

24
Concerns around AN

• Prolong suffering
• Complications from procedure Refeeding Syndrome
• Delays preparing for death
• When to stop feeding regime
• Costly labour intensive, especially HPN

25
Evidence for artificial Nutrition (AN) in
palliative patients

• Medically assisted nutrition for palliative care
  in adult patients. Cochrane database of
  Systematic Reviews, 2008, Good P, Cavenagh J,
  Mather M, Ravenscroft P
• No RCT or prospective controlled trials
• Conclusion Insufficient good quality trials to
  recommend medically Assisted Nutrition (AN) in
  palliative care patients

26
Evidence for venting PEG1?

• Retrospective study1 in 2002 looked at Palliative
  Venting Gastrostomy (PVG) over a seven-year
  period of 51 advanced cancer patients who had
  bowel involvement and symptoms of nausea and
  vomiting.
• Of these patients, 41 (92) had their symptoms
  relieved by PVG, and median survival after PVG
  insertion of all patients was 17 days

1Palliative venting gastrostomy in malignant
intestinal obstruction. M A Brooksbank, P A
Ashby Palliative Medicine, 2002 16 520
27
Hospital pathway for Venting PEG Artificial
nutrition in palliative (terminal) patients
28
Why was it needed?

• No guidance in place
• Patients dying badly from uncontrolled vomiting
• Terminal patients denied nutritional intervention

29
How the pathways were developed?

• Multi-professional team work
• Persistence!
• Mutual trust

30
Home Parenteral Nutrition (HPN) pathway for
terminally ill Patients with confirmed bowel
obstruction
Patient not eaten for gt5 days, hunger symptoms,
vomiting or dysphagia.
No
Prognosis 2-3 months?
Yes
Yes
Has patient capacity to consent?
Assessment by multi-professional teams involved
to agree decision on HPN
Address any symptoms-seek specialist advise if
unsure.
No
Not suitable for HPN
Yes
If indicated Venting PEG prior to transfer to St
Marks
Refer to St Marks Hospital by consultant
gastroenterologist. Discussion document with
patient/family on goals, limitations,
requirements, complications stopping HPN.
Consent form patient leaflet
Plan discharge support by St Marks
hospital/Macmillan service
31
If prognosis lt1 month

• Can consider PEG feeding regime
• Theory that some feed is still absorbed even in
  malignant bowel obstruction due to slow flow rate
• Benefit?

32
Pathway for Palliative venting gastrostomy (PVG)
in terminally ill patients with confirmed
irreversible bowel obstruction
Uncontrolled vomiting due to confirmed bowel
obstruction patient has capacity to consent
Under specialist advise, try control the pain
vomiting symptoms with a Syringe Driver using
various medications such as morhpine, midazolam
5-10mg, Buscopan 60-120mg, Dexamethasone 12-16mg,
cyclizine 150mg, nozinan 6.25-25mg, octreotide
300-1.2mg. (Minimum trial of 48 hrs)
NO
Are symptoms controlled?
Yes
Does 24 hour NGT trial 14F relieve symptoms?
NO
Remove NGT, sedate patient
surgical/gastro/nutrition/palliative assessment
for consideration of Venting PEG.
Venting equipment for discharge EOLC planning
including info for community team
Yes
Pain review by Macmillan team pre/post PEG
33
Summary

• Consider venting Peg for uncontrolled vomiting
  2nd to irreversible malignant bowel obstruction
• Remember to consider artificial feeding if
  ethically appropriate PEG or HPN
• End of life does NOT mean End of Care!

34
Finally, remember.
35
The Art of medicine