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NUTRITION M N GEMENT IN
P LLI TIVE C RE
PENATALAKSANAAN NUTRISI PADA
PERAWATAN PALIATIF
SURYANI AS’AD
2 nd MAKASSAR ANNUAL MEETING ON CLINICAL NUTRITION & PDGKINATIONAL CONGRESS
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
24-26 April 2015
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2
LapSus 1
LAPORAN KASUS
NUTRITION MANAGEMENT
IN PALLIATIVE CARE
I.INTRODUCTION
II.PALLIATIVE CARE
III.NUTRITION MANAGEMENT
IV.CONCLUSION
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I. INTRODUCTION
• PALLIATIVE : Latin “pallium”
• In 1990, WHO : TOTAL CARE
• 2005 : COMPREHENSIVE- INTEGRATIF –HOLISTIC CARE
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Let food be your medicine and let
medicine be your food” Hippocrates
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II. PALLIATIVE CARE
• Palliative care is a multidisciplinary approach
to specialised medical care for people with
serious illnesses. It focuses on providing
patients with relief from the symptoms, pain,
physical stress, and mental stress of a serious
illness—whatever the diagnosis. The goal of
such therapy is to improve quality of life forboth the patient and the family
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• WHO definition:
– …improves quality of life of patients and their
families
– ……prevention and relief of suffering
– …..early identification,… assessment and
treatment of
– …. problems, physical, psychosocial andspiritual.
PALLIATIVE CARE
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PALLIATIVE CARE IN INDONESIA
• START 19 February 1992, SOME HOSPITALS:
• Dr. Soetomo (Surabaya)
• Cipto Mangunkusumo (Jakarta)• Kanker Dharmais (Jakarta)
• Wahidin Sudirohusodo (Makassar)
• Sardjito (Yogyakarta)• Sanglah (Denpasar).
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III. NUTRITION MANAGEMENT
GOALS OF CARE
(Maintain quality of life; avoid prolongation ofdying)
- APPROACH TO PATIENS AND FAMILY
- ETHICAL PRINCIPLES- NUTRITION INTERVENTION
- NUTRITION CHALLENGES
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Approach to patients/families
Comfort always
Prolong life
Restore function
NUTRITION CARE
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– Autonomy
– Beneficence
– Non-maleficence
– Informed consent
ETHICAL PRINCIPLES
Beauchamp and Childress. Principles of Biomedical Ethics. New York:Oxford University Press. 1994 (4th Ed.)
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NUTRITION IN PALLIATIVE CARE
• HOSPITALIZE
• HOME CARE
• DAY CARE• RESPITE CARE
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Nutrition M N GEMENT
sUBYEKTIF
O
BJEKTIF
SSEssment
planning
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STEPS IN
NUTRITION M N GEMENT
stabilisaTiON
transiTiON
rehabilitaTiON
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6 LANGKAH PENTING
1. MENGATASI DAN MENCEGAH HIPOGLIKEMIA
2. MENGATASI DAN MENCEGAH HIPOTERMIA
3. MENCEGAH DAN MENGATASI DEHIDRASI4. KOREKSI GANGGUAN ELEKTROLIT
5. KOREKSI DEFISIENSI ZAT GIZI MIKRO
6. LAKUKAN STIMULASI SENSORIK DANDUKUNGAN EMOSI/MENTAL
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• Failure to achieve balance
1. Decreased intake
• Anorexia, xerostomia, alteredtaste/smell, odyno/dysphagia
2. Decreased absorption
3. Altered energy utilization
Challenges in NUTRITION
MANAGEMENT PC
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• Anorexia (loss of appetite)
–Multi-factorial
–“Cytokines”: central (hypothalamic)and peripheral (via vagus nerve)
influences
–Huge frustration for families, source
of much tension
Decreased intake
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1. Symptom control (nausea, pain)
2. Meal selection, timing,portion/presentation
3. Avoid/reduce conflict (eat, drink, be
merry): “eat what, where, when, asmuch/little as you want”
4. Natural resources
Approach in anorexia
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Appetite stimulants (progestational agent:
megestrol) may increase intake , body
weight, and quality of life, but they do not
affect prognosis in the terminally ill
Pharmacology in anorexia
Dy, M. “Enteral and Parenteral Nutrition in
Terminally Ill Cancer Patients: a Review of the
Literature.” American Journal of Hospice and
Palliative Medicine. 2006; 23 (5): 369-377
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• Nausea• Emesis
• Diarrhea
• Surgical/anatomical changes
Altered energy metabolism
Decreased absorption
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Algoritma Metode Pemberian Nutrisi
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• Ethical Principles
– Autonomy
– Beneficence
– Non-maleficence
– Informed consent
Role of Artificial Nutrition
Beauchamp and Childress. Principles of Biomedical Ethics. New York:Oxford University Press. 1994 (4th Ed.)
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ARTIFICIAL HYDRATION - NUTRITION
• Artificial hydration and nutrition can provide peoplewith fluids and foods when they are no longer able toeat or drink.
• Includes intravenous (IV) fluids, tube feeding, and IVnutrition (Total Parenteral Nutrition - TPN)
• Artificial hydration and nutrition is not necessary toprovide comfort in the last stages of life.
• It may actually make a person more uncomfortable bycontributing to shortness of breath, swelling, vomiting,diarrhea, and cramps. Artificial hydration and nutritionwill not bring a person back to a healthy condition.
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Acetylcholine (ACh): mengawasi aktivitas daerah
otak yang ada hubungannya dengan perhatian,
dan memori.
Glutamat : eksitator neurotransmitter otak yang
penting, vital untuk membentuk hubungan antar
neuron yang merupakan dasar dari memori jangka
panjang
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IV. CONCLUSIONNUTRITION MANAGEMENT IN
PALLIATIVE CAREIMPORTANT
ETHICAL ASPECT
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Nutrien yang sering digunakan
• Serat larut----mengikat HDL
• Folat---mengurangi homosistein
(a.a.berpotensi peny.jtg)• Omega-3, omega-9 (meningkatkan
imunitas, menurunkan LDL, meningkatkan
HDL)• Lemak tidak jenuh (monounsaturated fat)
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Starvation Cachexia
Appetite Late suppression Early suppression
BMI Not predictive of mortality Predictive of mortality
Albumin Low in late phase Low in early phase
Cholesterol May remain normal Low
Total lymphocyte
count
Low, responds to
re-feeding
Low, no response to
re-feeding
Cytokines Little data Elevated
Inflammation Usually absent Present
With re-feeding Reversible Resistant
IV. Cachexia versus Starvation
Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in
Geriatric Medicine. 2002; 18: 883-891
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Cachexia versus Starvation
Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in
Geriatric Medicine. 2002; 18: 883-891
• Starvation: pure protein/energy deficiency
(under-nutrition)
• Cachexia: cytokine-induced wasting of protein
and energy stores, caused by effects of disease
• Biochemical markers represent nutritional statusor illness severity?
• Acute-phase cytokine response
• Strong inverse correlation between IL-2R and
albumin, pre-albumin, cholesterol, Hgb
• Common pathway to reduction in albumin, etc.
may be cytokine induction, rather than absence
of nutrients
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