1. Nutrition and Hydration
A Palliative Approach to Care

2. 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

3. 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

4. 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.