1. Nutrition and hydration in palliative care
Hannah Roberts
Specialist Upper GI Cancer Dietitian
Bradford Teaching Hospitals

2. Aims Know the different types of nutrition support available
Be able to choose and justify the most appropriate method of nutrition support for palliative patients
Consider the ethical and moral arguments for artificial nutrition
Understand the role of the dietitian in palliative care

3. Quick Quiz! Name 2 benefits of nutrition support in palliative care
Name 2 risks of nutrition support in palliative care
Give an example of food fortification
Give an example of a supplement drink that needs to be prescribed
What is enteral nutrition? Give an example
What is parenteral nutrition?

4. Do the benefits outweigh the risks?
Ethics and legality
Hydration is basic care
Spoon feeding is basic care
Artificial nutrition is not basic care and classed as a medical intervention
Key question:
Do the benefits outweigh the risks?
Oral nutrition and hydration should always be provided unless actively refused by the patient
Medical team can deny a patient artificial nutrition – it is not a basic right.
Ethics surrounding whether or not to commence artificial nutrition are complex.
Emotive area. Raises issues such as should people in this country be allowed to starve?
Focus on nutrition in this presentation. Not going to say whether it is right or wrong to feed.
To try and decide whether a patient should receive any nutrition support in palliative care you need to have a good understanding of the options available.

5. Once started can you stop?
Legal equivalence of withdrawal and withholding
Can feel more comfortable not to start than to start and then discontinue
Don’t deny patient the right of a trial of therapy
Can trial with agreed objectives and time for review
If artificial nutrition has been started can it be stopped?
Common reason not to start using artificial nutrition in palliative care is that a decision will be needed about withdrawing feeding in the future maybe due to patient’s deterioration.

6. Hydration Good hydration essential for well-being
Adequate fluid provision should not impair appetite
Nourishing fluids

7. Benefits of nutrition support in palliative care
Increase energy levels
Resistance to infection
Minimise muscle wasting and pressure sores
Allows patient to retain some control over their illness
Helps to maintain a sense of normality
Can improve quality of life and sense of well being
Eating can be a big part of people’s lives and not being able to eat has a significant impact on quality of life.
Not eating sufficient leads to reduced energy levels and can reduce intake further.
Nutrition can help to retain physical strength long enough to fulfil final wishes/ambitions
Enables physical strength to obtain benefit from any physiotherapy/occupational therapy
Patient can die with some dignity and not as a result of starvation

8. Risks of nutrition support in palliative care
Aspiration
Sepsis
Haemorrhage
Can prolong death
Evoke feelings of fear and despair
Food intake is associated with health and wellbeing for those patients struggling to eat they may feel isolated and depressed

9. When to use nutrition support
Disease related malnutrition
Weight loss
Reduced appetite and early satiety
Swallowing difficulties
Also depends on stage of disease
Curative phase – always appropriate
Palliative phase – usually appropriate
Terminal phase – rarely appropriate
Obvious nutritional difficulties but a patient may have some of those problems and it still might not be appropriate to have any nutritional intervention.
Consider the burden vs. benefit equation – balance shifts with phase of illness

10. Types of nutrition support
Oral
Enteral
Parenteral
3 broad classifications

11. Oral nutrition High energy and high protein diet Food fortification
Appetite stimulation
Using full fat foods – too many palliative patients still trying to eat healthily using low fat spread and skimmed milk!
Food fortification – adding calories without adding bulk e.g. add cream to soup, extra butter on toast, full fat milk in mashed potatoes, cheese to scrambled eggs etc….
*Eating with a small appetite diet sheet*
Appetite can be stimulated using fresh air, small amount alcohol and low dose steroids

12. Food Fortification Breakfast Porridge Toast + butter Cup of tea Lunch
Cup-a-soup
Banana
Evening meal
Poached cod and jacket potato
Yoghurt
Extras
Tea between meals
Horlicks at supper
Total: 980 calories and 48g protein
Audience to suggest ways of fortifying menu

13. What difference can food fortification make?
Breakfast
Porridge….. Swap to whole milk and add golden syrup
Toast + butter….. Add jam
Cup of tea….. Make with whole milk
Lunch
Soup….. Swap to a creamy soup
Add bread and butter
Banana….. Add custard
Evening meal
Poached cod….. Add a cheese sauce
Jacket potato….. Add butter
Yoghurt….. Swap to a trifle
Extras
Tea between meals….. Make with whole milk
Horlicks at supper….. Make with whole milk
Add 2 biscuits and a slice of cake
Total: 2070 calories and 75g protein
That’s an extra 1090 calories and 27g protein!!

14. Oral nutrition Supplements (many different types!)
- high energy and high protein drinks
- high energy “medicine”
- puddings
- powders
Supplement samples

15. Oral nutrition – when to use it
If a patient can eat let them eat!
Majority of palliative care patients
Encourage higher calorie options (if liked)
Use of supplements if a patient can’t eat “enough”
Remember offering food and ensuring a patient has help at meal times if needed is a basic care
“enough” – varies between patients
Is a patient is willing to try supplements? *Copy of when to prescribe supplements (Guidance for GPs)*
Some patients feel they can benefit and improve sense of well being. But can divert patients attention from the food they want to eat, not always liked and patients may feel guilty if they are unable to take them.
Example: patient who didn’t get up until the afternoon due to a lack of energy, started on supplements and he felt they gave him some extra energy and was able to get up earlier and get some fresh air in the garden!

16. Enteral nutrition “using a tube” Naso-gastric (NG) Naso-jejunal (NJ)
Gastrostomy e.g. PEG, RIG
Jejunostomy
Artificial feed (as recommended by the dietitian) is put down the tube via a pump or syringe
Medication and fluids can be put down too
Can be sole source of nutrition or to supplement oral intake
Requires a motivated carer and patient – needs training to administer feed if still living at home.
Body image issues

17. Enteral nutrition – when to use it
Depends on the individual patient
Unable to take nutrition orally
Persistent swallowing difficulties
As a result of increasing debility or dysphagia, a point may be reached when adequate nutrition can only be maintained by enteral feeding. For some patients may be a beneficial first step and for others it may not be appropriate as it may prolong the dying process.
Decision needs to be made as part of a multi-professional team.
Many factors to consider when deciding whether or not to use enteral nutrition e.g. aims of treatment (is it to prolong life or to maximise comfort?), prognosis, stage of illness, patient and family wishes
Differences between head and neck cancer and upper GI- more palliative head and neck cancer patients are enterally fed compared to upper GI due to prognosis (better in head and neck) and treatment (can completely stop a patient eating in head and neck).

18. Parenteral nutrition Through a vein
Requires appropriate access (usually through a central line)
Home parenteral nutrition is rare in palliative care in England
More common in Europe and USA
Leeds and Hope hospitals are the nearest centres

19. Parenteral nutrition – when to use it
Should it be used at all in palliative care?
Non-functioning GI tract e.g. intestinal failure
Do the risks outweigh the benefits?
Burdens and complications often outweigh any benefit

20. Case study 1 67 year old male with laryngeal cancer
April 04 - total laryngectomy
Oct 06 - dysphagia
CT scan showed bulky lymph node recurrence
Managing soft diet but not meeting nutritional requirements
NG tube inserted. Discharged home with NG feed.
Completed palliative chemoradiotherapy
Feb 07 - weight gain and improvement in oral intake. NG tube removed
July 07 - represented with lower oesophageal dysphagia on a liquidised diet and sip feeds. Oesophageal stent inserted and oral intake improved
Dec 07 - general deterioration, weight loss, minimal oral intake, poor prognosis
Patient and family – “could he have another NG tube please?”

21. Case study 1 – issues raised
Would NG feeding be of benefit to the patient?
Do we have the right to refuse to artificially feed?
What actually happened?
NG tube placed 10th December and commenced feeding.
Discharged to Manorlands Hospice with feed on 17th December.
Stopped using NG tube on 20th December.
Patient died on 24th December.

22. Case study 2 60 year old female
May 06 - Diagnosed with locally advanced pancreatic cancer
For palliative chemotherapy
12% weight loss in 6 weeks
Early satiety and poor appetite
Steattorhoea
Following a low fat diet
Blood sugar readings 20+ mmol/l
What is the most appropriate method of nutrition support for this patient?
No distant metastases but not operable

23. Case study 2 – issues raised
Review of diabetes medication
Commence pancreatic enzymes
Not a low fat diet!
Food first
High energy and high protein diet
Food fortification
Nutritional supplements
Avoid unnecessary consumption of simple sugars but not at the cost of energy intake
Supplements milk based drinks, energy and protein powder, liquigen

24. The last few days
Food and fluids for pleasure and comfort not for survival
Consider patient’s wishes, anxiety and physical symptoms
Nutrition support not usually appropriate
Artificial hydration is controversial
Do intravenous fluids provide symptomatic relief?
Does it satisfy thirst, confusion headaches?
Is it unnecessarily invasive?
Senior doctor has ultimate responsibility although a competent patient has the right to refuse (incompetent patients can refuse via an advanced refusal
As for any decision in terminal care primary goal is patient comfort therefore any decision should be made on this basis

25. The role of the dietitian in palliative care
Advice on:
poor appetite
sore or dry mouth
taste changes
early satiety
GI symptoms
Assessing nutritional needs and problems
Establishing which nutritional support measures are appropriate
Use of appropriate supplements
Enteral and parenteral nutrition support
Advice and guidance to carers
Training of staff and catering
Also working with catering services in institutions for appropriate food provision
Bradford dietitians are based at St Luke’s Hospital.
Telephone number:

26. Conclusions
Range of nutritional support options available to use in palliative care
Deciding when to use nutrition support can be difficult
Decision should be made as part of a multi-professional team (including the patient!)
Discussions should happen earlier rather than later