Nutrition and Hydration
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This document summarizes research on nutritional support and hydration for patients near the end of life. It finds that while patients have autonomy to choose artificial nutrition/hydration, such interventions often provide little benefit and can cause harm. Studies show artificial nutrition does not improve outcomes or quality of life and may increase risks like infection. Near death, most patients experience reduced hunger and intake, with few reporting hunger until death. Non-invasive comfort measures usually meet nutritional needs better than medical interventions in the dying process.
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Nutrition and Hydration
- 1. Nutritional Support and Hydration for Patients Near the End of Life Developed by Barry M. Kinzbrunner, MD Chief Medical Officer VITAS Healthcare Miami, FL
- 2. Objectives • Examine how the cardinal ethical values impact decision-making regarding nutritional support and hydration at the end of life • 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
- 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 • May artificial feedings/hydration be withdrawn?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. Cardinal Principles of Medical Ethics Principle Definition Autonomy Self-determination by choosing among available treatment options Beneficence Taking action for the patient’s benefit Non-maleficence Avoiding harm Justice: Societal Distributive Doing what is good for the society as a whole Allocating resources wisely Kinzbrunner BM: Introduction in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. xvii.
- 5. 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
- 6. Nutrition & Hydration: 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
- 7. Nutrition & Hydration: Non-Maleficence Belief that artificial nutrition and hydration: • Reduces aspiration pneumonia risk • Is a low risk procedure to the patient • Reduces hunger and thirst
- 8. Nutrition & Hydration: Justice Social Justice • 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
- 9. Nutrition & Hydration: Justice (Cont.) Distributive Justice • 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
- 10. 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 569.
- 11. Nutrition Near the End of Life (Cont.) Direct effects of tumors & antineoplastic therapy • Abdominal fullness • Taste change • Dry mouth • Constipation • Uncontrolled nausea and emesis • Dysphagia • Mechanical obstruction • Uncontrolled pain Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 569.
- 12. Nutrition Near the End of Life (Cont.) 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 571.
- 13. 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
- 14. 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.
- 15. Parenteral Nutritional Support (Cont.) 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 110:734, 1989.
- 16. Enteral Nutritional Support—Oral Terepka and Waterhouse, 1956 Metabolism of force-fed patients with cancer • Nine 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 20:225, 1956.
- 17. Enteral Nutritional Support—Oral (Cont.) Ovesen, Allingstrup, Hannibal, et al, 1993 Effect of dietary counseling…in cancer patients undergoing chemotherapy •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 11:2043,1993.
- 18. Enteral Nutritional Support—Tube Gastrostomy vs. NG-tube • % of prescribed intake – G-tube 93%; NG-tube 55% (p < 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 304:1406, 1992.
- 19. Enteral Nutritional Support— Tube (Cont.) Efficacy of Tube Feedings . 95.4 95 75.7 62 2.3 2.5 6 5 2.3 2.5 18.3 33 0 20 40 60 80 100 < 1 mo 1-2 mo 2-6 mo 6-11 mo Duration of tube feeding, months %Patients Stable Weight Weight Gain Weight Loss Ciocon JO, Silverstone, FA, Graver LM, Foley CJ: Tube feedings in elderly patients. indications, benefits, and complications. Arch Int Med 148:429-433.
- 20. Enteral Nutritional Support— Tube (Cont.) 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 < 0.01) Scott AG, Austin HE: Nasogastric feeding in the mangement of severe dysphagia in motor neurone disease. Pall Med 8:45, 1994.
- 21. Enteral Nutritional Support— Tube (Cont.) Mortality in Gastrostomy Patients Indication Mortality Rate % Mortality Neurologic debilitation 19/67 28% Head and neck cancer 2/16 12% Metastatic cachexia 3/8 37% Pulmonary cachexia 9/10 90% Postoperative inanition 1/2 50% Total 34/103 33% Stuart SP, Tiley EH, Boland JP: Feeding gastrostomy: A critical review of its indications and mortality rate. South Med J 86:169, 1993.
- 22. Tube Feeding in Patients with Dementia: A 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 Finucane TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999.
- 23. Review of published evidence regarding harmful effects of tube feedings: •Mortality – Perioperative mortality 6-24% – 30 day mortality 2-27% – One year mortality > 50% •Aspiration 0-66% Local infection 4-16% •Occlusion 2-34% Leaking 13-20% •2/3 of NG tubes require replacement Finucane TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999. Tube Feeding in Patients with Dementia: A Review of the Evidence (Cont.)
- 24. Pharmacologic Interventions Medication Dosage Steroids Dexamethasone 1.5-4 mg qd to qid Methylprednisolone 20 mg qd to qid Prednisone 20 mg qd to qid Megestrol acetate 160-400 mg bid Metoclopramide 10 mg tid ac and hs Tetrohydrocannibinol (THC) 2.5 mg tid Cyproheptidine 4 mg tid Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 573.
- 25. Pharmacologic Interventions (Cont.) Steroids • Improve appetite in 50-75% of patients with cancer • Effects within days • Maximum effect within four weeks • Effects fade over time • Side effects – Oral thrush – Edema and cushingoid features – Dyspepsia – Psychic changes – Ecchymoses Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 573.
- 26. Pharmacologic Interventions (Cont.) 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 573.
- 27. Pharmacologic Interventions (Cont.) 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 benadryl Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 574.
- 28. Pharmacologic Interventions (Cont.) 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 – Disassociation Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 574.
- 29. Pharmacologic Interventions (Cont.) Cyproheptadine • Borderline appetite stimulation compared to placebo • No weight gain • Increased somnolence and dizziness Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 575.
- 30. 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 576.
- 31. Non-pharmacologic Interventions (Cont.) • Dietary counseling to explain changing dietary needs to patient and family – Need for less food – Lifting of dietary restrictions Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 576.
- 32. Studies on Hunger at the End of Life 32 patients: recorded food and water ingestion Degree of Hunger # Pts (%) Normal Intake Reduced Intake Liquids Only None 20 (63%) 0 18 2 Present initially 11 (34%) 0 8 3 Present until death 1 (3%) 1 0 0 Total 32 (100%) 1 26 5 McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. J Am Med Assoc 272:1263, 1994.
- 33. Studies on Hunger at the End of Life (Cont.) 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 94:767, 1994.
- 34. Studies on Hunger at the End of Life (Cont.) Modification of nutritional behavior Results: •107 patients (92%) had meals until the day of death •Nine 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 94:767, 1994.
- 35. Symptoms of Hydration Near the End of Life Symptom Occurrence Treatment Thirst Common Oral fluid, ice chips Dry mouth Common Meticulous mouth care Artificial saliva Nausea & emesis Rare Symptomatic Rx Headache Not reported Cramps Not reported Postural hypotension Occasional Parenteral hydration may be indicated Lethargy Common but w/o distress in bedbound pts May protect against pain and other discomforting symptoms in bedbound ptsDrowsiness Fatigue Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 579.
- 36. Studies on Symptoms of Dehydration • Collaud et al: J Pain Symp Manag, 6:230, 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 311:753, 1984 – Elderly experience reduced thirst after water deprivation when compared to young
- 37. Studies on Symptoms of Dehydration (Cont.) • Burge: J Pain Symp Manag 8:454, 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
- 38. Effects of Hydration Near the End of Life Adapted from Rousseau P: How fluid deprivation affects the terminally ill. RN:54, 73, 1991. Organ System Effect of Hydration Renal Increased urinary output Increased need for catheter Increased infection risk Pulmonary Increased pharygeal & lung secretions Increased dyspnea, cough, congestion Increased risk of pulmonary edema Gastrointestinal tract Increased GI fluid output Increased risk of nausea & emesis Other body compartments Increased per-tumor edema Increased peripheral edema
- 39. Hydration Near the End of Life Common Methods of Delivery of Fluids •Intravenous – Peripheral IV – Central access port when available Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 579.
- 40. Hydration Near the End of Life (Cont.) • 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 581.
- 41. Hypodermoclysis Symptom-related medications that can be administered via this route •Pain – Morphine – Hydromorphone •Sedation & other CNS symptoms – Midazolam – Haloperidol – Phenobarbital – Dexamethasone •Gastrointestinal – Metoclopramide •Respiratory secretions – Atropine – Scopolamine Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 581.
- 42. Hypodermoclysis (Cont.) 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.
- 43. Studies on Hydration at the End of Life • Bruera et al: J Pain Symp Manag 1:287, 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
- 44. Symptoms of Thirst at the End of Life 32 patients: recorded food and water ingestion Degree of Thirst/Dry Mouth # Pts (%) Normal Intake Reduced Intake Liquids Only None 11 (34%) 0 8 3 Present initially 9 (28%) 0 9 0 Present until death 12 (38%) 1 9 2 Total 32 (100%) 1 26 5 McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. J Am Med Assoc 272:1263, 1994.
- 45. Studies on Hydration at the End of Life (Cont.) 2005: Randomized Clinical Trial • 1000 cc/day of parenteral fluid vs. placebo of 100 cc/day over 4 hours • 51 Patients were studied for two days • Symptoms evaluated: hallucinations, myoclonus, fatigue, sedation, global well-being and overall effectiveness • Investigators were also asked to rate global well-being and overall effectiveness Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.
- 46. Studies on Hydration at the End of Life (Cont.) Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.
- 47. Studies on Hydration at the End of Life (Cont.) Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.
- 48. Studies on Hydration at the End of Life (Cont.) 2005: Randomized Clinical Trial Conclusions •Parenteral hydration decreases some symptoms associated with dehydration (myclonus and sedation) •Hydration was well-tolerated •Definite placebo effect observed •Further studies involving a larger number of patients with a longer follow-up period are warranted Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.
- 49. 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 Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 583.
- 50. For those eligible to obtain CE credit: 1. Enter the following website information in your web browser: www.VIT.CmeCertificateOnline.com 2. Click on the following link: Nutrition and Hydration at End of Life – 11.10.16.16 3. You will be asked to complete a brief questionnaire, and your certificate will be available to print immediately afterward. A copy of the certificate will also be sent to you via email. Questions? Email [email protected]