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Nutrition and Hydration in the Hospice Patient
This document discusses the ethical considerations and practical applications of artificial nutrition and hydration (ANH) for hospice patients, emphasizing the benefits and burdens associated with tube feeding, particularly in advanced dementia cases. It highlights the importance of shared decision-making, exploring the role of patient autonomy and care goals. Key findings indicate that tube feeding may not significantly improve patient outcomes, and alternatives such as comfort feeding are recommended.
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Nutrition and Hydration in the Hospice Patient
- 1. Nutrition and Hydration inthe Hospice Patient
- 2. CE Provider Information VITAS Healthcare®programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/ Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS Healthcare® programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/ Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner. VITAS Healthcare®, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024. Social workers completing this course receive 1.0 ethics continuing education credits. VITAS Healthcare® Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
- 3. Goals • Describe theethical framework and practical application of artificial nutrition and hydration (ANH) for hospice patients • Help clinicians understand the specific types, risks, benefits, burdens, and complications of ANH • Provide evidenced-based answers to common questions about ANH for patients who are nearing the end of life • Explore the recommendations of leading care organizations about ANH • Provide supportive alternatives for patients as they near the end of life
- 4. Objectives • Apply ethicalprinciples to decisions surrounding artificial nutrition and hydration (ANH) near the end of life. • Identify the benefits, burdens, and harms of tube feeding (TF) in persons with advanced dementia. • Recognize the benefits, burdens, and harms of parenteral hydration in persons near the end of life.
- 5. Ethical Framework • Beneficence: Promotepatient well-being • Autonomy: Respect patient self-determination • Nonmaleficence: Do no harm • Justice: Protect vulnerable populations and provide fair allocation of resources
- 6. Withholding and Withdrawing Basic Need or Medical Intervention •Initiating a treatment does not mandate its continued use until the patient dies • Availability of a treatment does not mandate its use • To forgo or to withdraw a treatment is usually ethically and legally equivalent
- 7. Burdens and Benefits Through Shared Decision- Making(DM) to Delineate Goals of Care (GOC) • Diagnosis • Prognosis • Beliefs and values • Quality of life • Goals of care • Medical indications for treatment
- 8. Time-Limited Trials • May beconsidered when burden and benefit of treatment are uncertain • Delineate end points clearly • Ceasing ineffective or burdensome treatment may be preferable to no offering at all • Fears of withdrawal should not prohibit time-limited trials – Example: Time-limited trial of intravenous (IV) fluids to see if delirium resolves
- 9. Artificial Nutrition and Hydration Yes • Tube alimentarytract – PEG – NG – PEJ • Needle into vein or under skin No • Assisted oral feeding – Spooning – Syringing
- 10. When Can ANH Be Beneficial? •Cancer with bowel obstruction – Good functional status – Total parenteral nutrition (TPN) has demonstrated improved quality of life and possibly life prolongation • Stroke with a good prognosis – Often unclear during acute phase – Feeding tubes are often placed as part of a time-limited trial
- 11. Bottom Line • Useof artificial nutrition and hydration in many palliative care patients may be limited, yet risks and treatment burdens are substantial
- 12. ANH Scenarios: ALS and PEG Tubes •PEG tube indications: – Accelerated weight loss with dysphagia – Frequent choking – Exhaustion with eating – Impaired quality of life due to the stress surrounding eating • PEG tubes may prevent malnutrition and its complications, and may prolong survival if placed early in the disease course • Feeding tube placement may improve quality of life (QOL) • Place PEG prior to forced vital capacity (FVC) dropping below 50%
- 13. Tube Feedings • Risk ofaspiration • Mortality and morbidity related to the insertion procedure, morbidity from leaking, discomfort, blockage, or displacement • Chemical or physical restraints to avoid pulling of the tube
- 14. Tube Feeding forPatients with Advanced Dementia
- 15. Case Study of SH •83-year-old female who was diagnosed 6 years ago with advanced Alzheimer’s dementia • Admitted from home to hospital with pneumonia • Minimally verbal • Fair appetite with some weight loss over last 6 months • Instrumental activities of daily living (IADL)-dependent • ADL baseline: Able to walk from the chair to the bed with a walker and self-feed with her hands; incontinent of urine and stool
- 16. Case Study (cont.) • Medications: –Lisinopril – Metoprolol – Lipitor – Aricept – Ketoconazole • Lives with daughter, who is primary caretaker • Essentially homebound, patient not seen a physician in several years
- 17. Hospital Course • Antibiotics andIV fluids initiated • Poor oral intake • Increased confusion and sleepiness (delirium) • ADL now: Not able to get out of bed without assistance, needs to be fed, incontinent bladder and bowel • Should we put in a feeding tube?
- 18. Tube Feedings for Patients with Alzheimer’s •For patients with end-stage dementia, comfort feeding (CF) by hand is preferable to tube feedings • CF aligns with comfort, provides social interactions, and avoids complications of tube feedings • CF order can provide steps to ensure a patient’s comfort
- 19. Natural History ofDementia Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361, 1529-1538. • Median survival was 478 days, 24.7% within 6 months • 54.8% died, 93.8% in NH 6-month mortality 38.6% 6-month mortality 44.5% 6-month mortality 46.7% Overall Mortality and the Cumulative Incidences of Pneumonia, Febrile Episodes, and Eating Problems Nursing Home Residents with Advanced Dementia. Overall mortality for the nursing home residents during the 18-month course of the study is shown. The residents’ median age was 86 years, and the median duration of dementia was 6 years; 85.4% of residents were women.
- 20. Tube Feedings for Patients with Alzheimer’s (cont.) •Patients find the effort to eat or drink draining or unwelcome; they should not be pressured to make this effort • Symptoms of dry mouth and thirst can be alleviated with mouth care Arcand, M. (2015). End of life issues in advanced dementia. Canadian Family Medicine, 61(4), 330-334.
- 21. Antibiotics • Sometimes, antibioticsare prescribed for end-stage pneumonia to increase comfort, even when death is imminent • Withholding might be appropriate if the goal of care is symptom control without life prolongation Arcand, M. (2015). End of life issues in advanced dementia. Canadian Family Medicine, 61(4), 330-334.
- 22. Does not recommendpercutaneous feeding tubes in patients with advanced dementia. Instead, offer oral assisted feeding. Does not recommend percutaneous feeding tubes in patients with advanced dementia. Instead, offer oral assisted feeding. Does not recommend percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feeding.
- 23. Caregiver’s Perspective • Feeding tubesare inevitable • There are no alternatives • Awareness of only procedural risk(s) • Unclear about the patient’s prognosis • Expect tube feeding will improve comfort, nutrition, and longevity Marcolini, E., et al. (2018). History and perspective on nutrition and hydration at the end of life. Yale Journal of Biology & Medicine, 2(91), 173-176.
- 24. Questions Generated Do feeding tubes… •prevent aspiration pneumonia? • prevent malnutrition? • decrease the mortality rate? • prevent pressure sores or hasten their healing? • improve patient comfort? • improve functional status?
- 25. Do Feeding Tubes Prevent Aspiration Pneumonia? • Norandomized controlled trial of the intervention has been done • No data shows feeding tubes decrease the risk of aspiration pneumonia • Patients can still aspirate oral secretions • Feeding tubes are not shown to reduce the risk of regurgitated gastric contents
- 26. Lack of Healthcare Provider Education • 500PCPs surveyed • 75% of physicians thought that PEG tubes decreased the risk of aspiration • 90% thought that total enteral nutrition (TEN) in advanced dementia improved nutritional status • Most of the participants thought that tube feeding (TF) decreased the risk of pressure ulcers Lembeck, M., et al. (2016). The role of IV fluids and enteral or parenteral nutrition in patients with life limiting illness. The Medical Clinics of North America, 100(5), 1131-1141.
- 27. Actively Dying Patients Lembeck, M., etal. (2016). The role of IV fluids and enteral or parenteral nutrition in patients with life limiting illness. The Medical Clinics of North America, 100(5), 1131-1141. Benefit Burden Address patient/family preferences Increased secretions Address spiritual/religious preferences Edema/anasarca Prevent dehydration Loose stool Benefits vs. Burdens of IV Fluids
- 28. Financial Impact • For nursinghome (NH) residents with advanced dementia, clinicians must consider the comparative costs of caring for a resident via tube feeding (TF) vs. comfort feeding (CF) • Cost of daily time dedicated by staff was greater for TF vs. CF ($4,219 vs. $2,379) • Time spent feeding increased in TF Lembeck, M., et al. (2016). The role of IV fluids and enteral or parenteral nutrition in patients with life limiting illness. The Medical Clinics of North America, 100(5), 1131-1141.
- 29. Why Tube Feeding May Not Decrease Aspiration Pneumonia •Cricopharyngeal incoordination • Decreased esophageal motility • Altered esophageal sphincter tone • Impaired gastric emptying • Ineffectiveness of elevation of head of bed Lembeck, M., et al. (2016). The role of IV fluids and enteral or parenteral nutrition in patients with life limiting illness. The Medical Clinics of North America, 100(5), 1131-1141.
- 30. Questions Generated Do feeding tubes… •prevent aspiration pneumonia? • prevent malnutrition? • decrease the mortality rate? • prevent pressure sores or hasten their healing? • improve patient comfort? • improve functional status?
- 31. Studies of Tube Feeding and Nutrition •40 long-term care residents lost weight and depleted lean body mass over 1 year, despite tube feeding • Micronutrient and protein malnutrition existed, despite adequate formula • Pressure ulcer number was unchanged • Chronic disease, immobility, and neurologic deficits probably undermine nutritional support Henderson, C., et al. (1992). Prolonged tube feeding in long-term care: Nutritional status and clinical outcomes. Journal of the American College of Nutrition, 3(11), 309-325.
- 32. Studies of Tube Feeding and Nutrition (cont.) •126 patients receive a PEG, 75% are neurologically impaired and dependent in ADLs • Over 1 year, improvement in albumin of 1g/dL occurred in only 13.4% of patients; 5% had a decline • No significant improvement seen in any nutritional parameters • Stabilization of nutritional status may have occurred Callahan, C., et al. (2000). Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. Journal of the American Geriatrics Society, 48(9), 1048-1054.
- 33. Questions Generated Do feeding tubes… •prevent aspiration pneumonia? • prevent malnutrition? • decrease the mortality rate? • prevent pressure sores or hasten their healing? • improve patient comfort? • improve functional status?
- 34. Does Tube Feeding Prolong Survival Significantly? • Nopublished studies suggest tube feeding prolongs survival in dementia patients with dysphagia • Mortality rates remain consistently high following PEG placement in older adults with significant neurologic burden: – 30-day 20%-40% – 6-month 50% Teno, J., et al. (2012). Feeding tubes and the prevention or healing of pressure ulcers. Archives of Internal Medicine, 172(9), 697-701.
- 35. Mitchell, S., etal. (1997). The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine, 157(3), 327-332. Survival Comparison of Residents with Severe Cognitive Impairment, With vs. Without Feeding Tubes Survival Between Residents With vs. Without Feeding Tube
- 36. 1 Year Survivalfrom Baseline by FT Status Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival?. Journal of the American Geriatrics Society, 60(10), 1918-1921. 0 0 .25 .5 .75 1 100 200 300 400 Days from Baseline Survival FT No FT
- 37. Questions Generated Do feeding tubes… •prevent aspiration pneumonia? • prevent malnutrition? • decrease the mortality rate? • prevent pressure sores or hasten their healing? • improve patient comfort? • improve functional status?
- 38. PEG Tubes and Pressure Ulcersin Patients with Advanced Cognitive Impairment • Compared to patients without PEG tubes, those with PEG tubes were: – 2.27 times more likely to develop pressure sore(s) – 0.70 times less likely to experience healing of an existing pressure sore Teno, J., et al. (2012). Feeding tubes and the prevention or healing of pressure ulcers. Archives of Internal Medicine, 172(9), 697-701.
- 39. Why Not Offer Tube Feeding? •Tube-fed patients can experience increased incontinence, which can increase the risk of pressure ulcers • Tube-fed patients produce more urine, stool, and upper airway secretions • Tube-fed patients are more likely to be restrained
- 40. Questions Generated Do feeding tubes… •prevent aspiration pneumonia? • prevent malnutrition? • decrease the mortality rate? • prevent pressure sores or hasten their healing? • improve patient comfort? • improve functional status?
- 41. Dementia, Discomfort, and Cessationof ANH Pasman, H., et al. (2005). Discomfort in nursing home patients with severe dementia in whom artificial nutrition and hydration is forgone. Archives of Internal Medicine, 165(15), 1729-1735.
- 42. Feeding Tube Complications PEG Short-Term Localirritation Infection PEG occlusion Aspiration Bleeding Reflux Diarrhea Tube migration PEG Long-Term Restraint use Diminished QOL Frequent replacement/ removal No oral intake Limited socialization Poor mouth care Burdensome transitions
- 43. DM and Outcomes After PEG Decision-MakingProcess • 71.6% reported no conversation about tube • Risks not discussed in 1/3 cases • Discussion lasted less than 15 minutes • 51.8% thought MD was strongly in favor of tube • 12.6% felt pressure by MD to place tube • Worse end-of-life care Teno, J., et al. (2011). Decision-making and outcomes of feeding tube insertion: a five-state study. Journal of the American Geriatrics Society, 59(5), 881-886. Adverse Outcomes • Improved QOL 32.9% • Patient bothered 39.8% • Physical restraint 25.9% • Chemical restraint 29.2% • Either 34.9% • ED due to tube 26.8% • Feelings related to tube ⏤Regret 23.4% ⏤Right decision 61.9%
- 44. TF Insertion Ratesin NH Residents Mitchell, S., et al. (2016). Tube feeding in US nursing home residents with advanced dementia, 2000-2014. Journal of the American Medical Association, 316(7), 769-770. Residents With Advanced Dementia Year With Recent Onset of Total Dependence for Eating, No. With Feeding Tubes Over Subsequent 12 Months, No. (%) 2000 7029 820 (11.7) 2001 6738 774 (11.5) 2002 6239 701 (11.4) 2003 5518 577 (10.5) 2004 5194 462 (8.9) 2005 4628 398 (8.6) 2006 4389 393 (9.0) 2007 4110 357 (8.7) 2008 3890 331 (8.5) 2009 3842 297 (7.7) 2010 3794 283 (7.5) 2011 4538 264 (5.8) 2012 4246 235 (5.5) 2013 3685 207 (5.6) 2014 3411 193 (5.7)
- 45. Decision Making 1. Review theclinical issues 2. Establish the goals of care 3. Present options to manage the feeding problem 4. Weigh risks/benefits based on values/preferences 5. Determine how decisions affect the family member 6. Offer additional sources of decisional support 7. Provide ongoing support; recognize the need to revisit the decision Cervo, F., et al. (2006). To PEG or not to PEG: A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics, 61(6), pp. 30-35.
- 46. Case Study of HS Concludes •Family elects not to pursue a feeding tube • Patient transitions to hospice at time of discharge • About 4 weeks later, patient dies comfortably at home with minimal oral intake and good mouth care
- 47.
- 48. References Arcand, M. (2015).End of life issues in advanced dementia. Canadian Family Medicine, 61(4), 330-334. Callahan, C., et al. (2000). Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. Journal of the American Geriatrics Society, 48(9), 1048-1054. Cervo, F., et al. (2006). To PEG or not to PEG: A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics, 61(6), 30-35. Henderson, C., et al. (1992). Prolonged tube feeding in long-term care: Nutritional status and clinical outcomes. Journal of the American College of Nutrition, 11(3), 309-325. Lembeck, M., et al. (2016). The role of IV fluids and enteral or parenteral nutrition in patients with life limiting illness. The Medical Clinics of North America, 100(5), 1131-1141. Marcolini, E., et al. (2018). History and perspective on nutrition and hydration at the end of life. Yale Journal of Biology & Medicine, 91(2), 173-176. Mitchell, S., et al. (1997). The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine, 157(3), 327-332.
- 49. References Mitchell, S., etal. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361, 1529-1538. Mitchell, S., et al. (2016). Tube feeding in US nursing home residents with advanced dementia, 2000-2014. Journal of the American Medical Association, 316(7), 769-770. Pasman, H., et al. (2005). Discomfort in nursing home patients with severe dementia in whom artificial nutrition and hydration is forgone. Archives of Internal Medicine, 165(15), 1729-1735. Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? American Geriatrics Society, 60(10), 1918-1921. Teno, J., et al. (2012). Feeding tubes and the prevention or healing of pressure ulcers. Archives of Internal Medicine, 172(9), 697-701. Teno, J., et al. (2011). Decision-making and outcomes of feeding tube insertion: A five-state study. Journal of the American Geriatrics Society, 59(5), 881-886.