Nutritional Support and Hydration for Patients near the End-of-Life Barry M. Kinzbrunner, MD Chief...

Nutritional Support and Hydration for Patients near the

End-of-Life

Barry M. Kinzbrunner, MDChief Medical OfficerVitas Innovative Hospice CareMiami, FL

Objectives

• 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.

• Examine how the cardinal ethical values impact decision-making regarding nutritional support and hydration at the end-of-life.

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withdrawn?• May health care facilities deny care based on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?

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.

Nutrition & Hydration: Beneficence

BeneficenceBelief 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

Nutrition & Hydration: Non-Maleficence

Non-MaleficenceBelief that artificial nutrition and hydration:• Reduces aspiration pneumonia risk• Is a low risk procedure to the patient• Reduces hunger and thirst

Nutrition & Hydration: Justice

Social• 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

Distributive• 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

Nutrition Near the End of LifeCancer 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

Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York, McGraw Hill, 2002, p. 313.

Nutrition Near the End of LifeDirect effects of tumors and antineoplastic therapy• Abdominal fullness• Taste change• Dry mouth• Constipation• Uncontrolled nausea and emesis• Dysphagia• Mechanical obstruction• Uncontrolled Pain


Nutrition Near the End of Life

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


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

Parenteral Nutritional SupportAnalysis 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 .

Parenteral Nutritional SupportAmerican College of Physicians Position PaperParenteral 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.

Enteral Nutritional Support-Oral

Terepka and Waterhouse: 1956

Metabolism of force-fed patients with cancer• 9 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.

Enteral Nutritional Support-Oral

Ovesen et al. Effect of dietary counseling and diet on response to chemotherapy. 1993

• 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.

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.


Efficacy of Tube Feedings.

Ciocon JO, Silverstone, FA, Graver LM, Foley CJ: Tube feedings in elderly patinets. indications, benefits, and complications. Arch Int Med 148:429-433.

95.4 95

75.7

62

2.3 2.56 52.3 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

% P

ati

en

ts

Stable Weight

Weight Gain

Weight Loss


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.


Mortality in Gastrostomy Patients

Stuart SP, Tiley EH, Boland JP: Feeding gastrostomy: A critical review of its indications and mortality rate. South Med J 86:169, 1993.

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%

Tube Feeding in Patients with DementiaA 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

Fincune TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999.

Tube Feeding in Patients with DementiaA Review of the EvidenceReview of published evidence regarding harmful

effects of tube feedings:• Mortality

– Perioperative mortality 6-24%– 30 day mortality 2-27%– 1 year mortality > 50%

• Aspiration 0-66% Local infection 4-16%• Occlusion 2-34% Leaking 13-20%• 2/3 of NG tubes require replacement

Fincune TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia. J Am Med Assoc 282:1365, 1999.

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



Steroids• Improve appetite in 50-75% of patients with cancer• Effects within days• Maximum effect within 4 weeks• Effects fade over time• Side effects

– Oral thrush– Edema and cushingoid features– Dyspepsia– Psychic changes– Ecchymoses



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



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 benedryl


Pharmacologic InterventionsTetrahydrocannibinol• Primarily studied in HIV patients• Stimulation of appetite and mood, some weight gain• 2.5 mg tid • CNS toxicity (especially in elderly)

– Dizziness– Somnolence– Dissassociation

Cyproheptadine• Borderline appetite stimulation compared to placebo• No weight gain• Increased somnolence and dizziness


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

• Dietary counseling to explain changing dietary needs to patient and family

– Need for less food– Lifting of dietary restrictions


Studies on Hunger at the End-of-Life

32 patients, according to recorded food and water ingestion

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.

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

Studies on Hunger at the End-of-Life

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.

Studies on Hunger at the End-of-LifeModification of nutritional behaviorResults:• 107 patients (92%) had meals until the day of

death• 9 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.

Hydration Near the End of LifeSymptoms of Dehydration

Kinzbrunner BM: Nutritional Support and Parenteral Hydration. Chapter 16 in Kinzbrunner BM, Weinreb NJ, Policzer JS (eds). Twenty common problems in end of life care. New York,

McGraw Hill, 2002, p. 313.

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 pts

Drowsiness

Fatigue

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

• 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

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

Hydration near the End-of-Life

Common Methods of Delivery of Fluids• Intravenous

– Peripheral IV– Central access port when available

• 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


HypodermoclysisSymptom-related medications that can be administered via this route• Pain

– Morphine– Hydromorphone

• Sedation and other CNS symptoms– Midazolam– Haloperidol– Phenobarbital– Dexamethasone

• Gastrointestinal– Metoclopramide

• Respiratory secretions– Atropine– scopolamine


HypodermoclysisPotential 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.

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

Symptoms of Thirst at the End-of-Life

32 patients, according to recorded food and water ingestion

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.

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

ConclusionsPrinciples 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


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