Nutrition and Hydration A Palliative Approach to Care

Nutrition & Hydration Nutrition and hydration issues for residents receiving a palliative approach involve ethical decision making for the aged care team, resident and family members Nutritional intake of residents in RACF is a clinical and quality of life issue

Holistic Aspects of Nutrition Physiological Social – sharing meals Personal taste preferences Cultural food preferences Nutrition and hydration associated with more than just physiological need. Sharing meals is about social gathering. This can be difficult if resident no longer able to eat or enjoy food. There may be a sense of alienation from the group. Others concerns and pressure to eat to please others can have negative impact on resident. Difficult to enjoy individual food preferences, especially cultural preferences when mostly eating communal diet. Information about food preferences from resident and family guide meal planning by dietician

Nutrition Most common nutritional problems for residents in RACF are Weight loss Associated protein energy malnutrition Depression Adverse medication side effects Weight loss may be worsened by loss of appetite, however it is primarily a change to the body’s metabolism. Depression and adverse medication side effects are the most common treatable causes of malnutrition. Refer to Guideline 21 in Guidelines for a Palliative Approach in Residential Aged Care.

Nutrition Factors affecting poor nutritional status Advanced dementia Apathy Fatigue Paranoid behaviour Assessment for dysphagia important to provide direction for oral feeding Paranoid behaviour may take the form of the resident believing that they are being poisoned by food or fluid offered by carers. Investigations of dysphagia by a speech therapist may include assessment of swallowing mechanisms of the pharynx and larynx.

Potentially reversible causes Metabolic disorders such as thyroidism Chronic infections Alcoholism (nutrient malabsorption) Oral health factors Use of therapeutic diets Vitamin deficiencies Therapeutic diets such as low salt and low cholesterol diets can be associated with weight loss, low albumin levels and postural changes. Vitamin deficiencies – low levels of Vitamins B1, B2 and C have been associated with cognitive dysfunction. Supplementation of thiamine has improved cognitive function for older persons in RACFs with vitamin deficiencies

Oral Nutrition Oral nutrition rather than nasogastric enteral feeds is best practice management for older persons Requires diligent hand feeding program carer assisting with feeding should be seated at eye level with the resident take time to establish a relationship create a relaxing atmosphere Important to have assessment of dysphagia before embarking on oral feeding program. The preferences of the resident for food and fluid guide the dietician in planning meals. Not all residents will be willing or able to eat planned diet or take supplements. The focus will be to encourage residents to eat for comfort and enjoyment. To create a relaxing atmosphere - make sure resident is comfortably seated surrounding are clean and tidy, especially where food tray is placed non-hurried and friendly approach Refer to Guideline 22 in Guidelines for a Palliative Approach in Residential Aged Care.

Nutrition at End-of-life Eating and drinking may no longer be of interest to the resident entering the end-of-life phase When interest in food and fluid becomes minimal the individual should not be forced to receive them Family will sometimes have difficulty in accepting that a resident is no longer interested in eating or drinking. It can be helpful to explain to the family as simply as possible that when swallowing becomes a problem it may cause distress for the resident to be offered food. Because of the loss of the swallowing reflex, fluids may cause coughing and spluttering which may be distressing to the resident. Small sips of fluid or ice chips can be offered. Refer to Guideline 25 in Guidelines for a Palliative Approach in Residential Aged Care.

Artificial hydration Artificial hydration should be considered in the palliative approach where dehydration results from potentially correctable causes: over treatment of diuretics and sedation recurrent vomiting diarrhoea hypocalcaemia A blanket policy of no artificial hydration for a resident in the palliative phase is not recommended. Quality of life and comfort from distressing symptoms is the most important consideration. There are times when artificial hydration can reverse a distressing symptom for the resident. The impact of a hospital stay on the resident and their family would also need to be taken into account. Refer to Guideline 24 in Guidelines for a Palliative Approach in Residential Aged Care.

End-of-life The provision of artificial nutrition and hydration may be detrimental to the dying person The desire to feed stems from the belief that dehydration in a person close to death is distressing Thirst or dry mouth in residents who are at end-of-life may frequently be caused by medication, mouth breathing or oral thrush. In such cases artificial hydration is unlikely to alleviate this symptom. Good mouth care and reassessment of medication become the most appropriate interventions. Good mouth care involves cleaning the teeth or dentures with water and toothpaste on a small soft brush. The oral mucosa and tongue can also be brushed with a soft brush. Oralbalance is a suitable lubricant for the mouth. Family can purchase this from a pharmacy without a prescription. Oral thrush can be treated with nystatin (Nilstat drops). Refer to Guideline 26 in Guidelines for a Palliative Approach in Residential Aged Care.

Artificial Hydration Adverse effects of fluid accumulation caused by artificial hydration at end-of-life: increased urinary output increased fluid in GI tract – vomiting pulmonary oedema, pneumonia respiratory tract secretions ascites IV or SC fluids can be burdensome to the resident. Painful needle insertion and the need for immobilisation to maintain the line can be a problem for the resident. The need for admission to hospital for this therapy can be distressing tot he resident and family.

Feeding at end-of-life Continuing PEG feeding at end-of-life may pose a burden on the dying person Discussion with resident and carers to review benefits against potential burden Resident’s best interests and preferences guide decision making PEG – percutaneous endoscopy gastrostomy Continuinf feeding may cause discomfort to the resident as body may be unable to tolerate level of intake. Family or carers may find this a difficult time as they may be faced with decisions about stopping the feeds. Some may think that they are starving their loved one and need clear information about the resident’s ability to tolerate the food being offered.

Tube feeding decision aid Information on options and outcomes Steps to decision making that are based on the resident’s preferences, personal values and clinical situation A documented treatment plan designed to put these steps into operation Residents and families need to be able to access information pertaining to artifical feeding to ensure that they can make an informed decision Refer to: Tube feeding decision aid - Table 12 in Chapter 6 of the Guidelines for a Palliative Approach in Residential Aged Care.

Summary Nutrition and hydration issues involve ethical decision making Assessment and management of treatable causes Potential for burden at end-of-life Tube feeding decision aid Discussion regarding befits vs potential burden at end of life. Tube feeding decision aid p. 92 of Guidelines for a palliative approach in residential aged care facilities.