Module 11

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The
EPEC-O
TM
Education in Palliative and End-of-life Care -
Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM
Project with major funding provided by NCI, with
supplemental funding provided by the Lance
Armstrong Foundation.
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EPEC - Oncology Education in Palliative and
End-of-life Care - Oncology

• Module 11
• Withdrawing Nutrition, Hydration

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Overall message

• Withholding or withdrawing a therapy, such as
  artificial nutrition or hydration, is ethical and
  legal in some circumstances

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Objectives

• Withholding or withdrawing therapy
• Evidence base for artificial nutrition and
  hydration
• Approach to discussing artificial nutrition and
  hydration
• Features of artificial nutrition and hydration
  that favor use in spite of the evidence

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Video
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Role of the oncologist . . .

• Help the patient and family
• Elucidate their values
• Understand the facts
• Dispel misconceptions
• Establish goals of care
• Facilitate decisions, reassess regularly

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. . . Role of the oncologist

• Discuss alternatives
• Including palliative and hospice care
• Document preferences, medical orders
• Involve, inform other team members
• Assure comfort, non-abandonment

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Life-sustaining treatments

• Resuscitation
• Elective intubation
• Surgery
• Dialysis
• Blood transfusions, blood products

• Diagnostic tests
• Artificial nutrition, hydration
• Antibiotics
• Other treatments
• Future hospital, ICU admissions

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Enteral nutrition

• NG, PEG, J tubes
• Use GI tract
• Temporary inability to eat
• Neurological injury
• UGI mechanical obstruction

Shike M. Hematol Oncol Clin North Am, 1996.
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Effect of enteral nutrition on survival

• Higher mortality
• 50 dead at 12 months
• 60 dead at 18 months
• No reduction in aspiration
• No reduction in risk of pneumonia
• No evidence of better symptom control

Finucane TE, Christmas C, Travis K. JAMA, 1999.
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Parenteral nutrition

• Intravenous (central line)
• No benefit in routine perioperative, ICU settings
• Benefit in prolonged GI tract toxicity
• Benefit in absence of GI tract function in
  otherwise healthy patient (short gut)

Mercandante S. Support Care Cancer, 1998.
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Effect of parenteral nutrition on survival and
response rates
Odds ratio
Control 1.00
Survival 0.81 p lt 0.05
Tumor response 0.68
ACP Consensus Statement. Ann Int Med, 1989.
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Evidence conclusion

• When cancer is the cause of the anorexia and
  weight loss, prospective randomized studies have
  failed to show benefit of artificial nutrition

ACP Consensus Statement. Ann Int Med, 1989.
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Parenteral hydration

• Intravenous
• Subcutaneous (hypodermoclysis)
• Equally efficacious, less risk, less skill, less
  cost
• Doesnt relieve dry mouth

McCann RM, Hall WJ, Groth-Juncker A. JAMA, 1994.
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Common concerns

• Legally required to do everything?
• Is withdrawal, withholding euthanasia?
• Are you killing the patient when you withhold or
  withdraw artificial nutrition and hydration?

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7 steps to discuss nutrition hydration . . .

• Be familiar with policies, statutes
• Appropriate setting for the discussion
• Ask the patient, family what they understand
• Discuss general goals of care

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. . . 7 steps to discuss nutrition hydration

• Establish context for the discussion
• Discuss specific treatment preferences will
  nutrition hydration achieve goals?
• Respond to emotions
• Establish and implement the plan
• Reassess and revise periodically

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Address misperceptions

• Cause of poor appetite, fatigue
• Relief of dry mouth
• Urine output

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Emotions

• Not fighting
• Not doing something
• Starving to death
• Dehydrating to death
• Let nature take its course

McClement, et al. J Palliat Med, 2003.
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Help family and staff

• Identify feelings, emotions, need to do
  something
• Identify other ways to demonstrate caring
• Teach the skills they need

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Normal dying

• Loss of appetite
• Decreased oral fluid intake
• Artificial food / fluids may make situation worse
• Breathlessness
• Edema
• Ascites
• Nausea / vomiting

Ganzini L, et al. N Engl J Med, 2003.
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Discussing hospice care

• Hospice care - present as a response to need vs.
  something to do when nothing left to do
• Elicit patient and family understanding of
  situation
• 10-15 of patients referred to hospice care
  disenroll (graduate)

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Summary

• Withholding or withdrawing a therapy, such as
  artificial nutrition or hydration, is ethical and
  legal in some circumstances