Nutrition
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Nutrition

Key Messages

  • Decreased oral intake and weight loss is normal for people receiving palliative care. [1]
  • Focus of nutrition support for people in the palliative stage should be for quality of life and comfort. [2]
  • Enteral (EN) and parenteral nutrition (PN) is not generally recommended in palliative care [3] particularly for people with advanced dementia. [4]
  • Artificial hydration may exacerbate medical symptoms while not relieving symptoms of dehydration. [5]
  • It is important to consider cultural significance and symbolic value of artificial hydration and nutrition to the patient and family. [5, 6]
  • Ultimately the clinical decision regarding artificial nutrition or hydration is the responsibility of the medical team. [6]

Background

Ageing and associated deterioration in health can have a negative impact on nutritional status for the individual. Generally, there is a growing concern for undernutrition or malnutrition in older adults, and a wealth of literature and guidelines are available for the management of undernutrition in older adults. [1,3,4] However, in palliative care, the goal may become to optimise quality of life through food, rather than the attainment of adequate nutritional intake. [1] Controversy can occur around when to provide nutrition support, when it should be discontinued, and who makes this decision. [5]

Evidence Summary

While the literature does not specifically focus on older adults, many of the recommendations for nutrition support are applicable to this cohort as much as the adult population. It is common for all people receiving palliative care to have a reduced oral intake, reasons can include physical obstruction, swallowing difficulties, cachexia, weakness, loss of desire to eat or the person can become increasingly sleepy and therefore less able to receive oral nutrition. [1] When caring for people receiving palliative care, the impact of discontinuing or not being seen to offer and support nutrition and hydration can be confronting. In addition, the decision to discontinue support may not be aligned with cultural expectations for end of life care. [5] Families of people receiving palliative care can also often feel that care staff underestimate the distress experienced by the person when they are not eating or drinking normally, particularly if there is subsequent weight loss. [6]

While a number of strategies can be implemented for nutrition management, from counselling and oral nutrition support to medically assisted nutrition, the goal remains maintaining quality of life and comfort for the person. Oral nutrition support should only be used with the intention of maintaining and not improving nutritional status. [2] For people unable to tolerate oral diet and fluids, medically assisted nutrition support such as enteral (EN) and parenteral nutrition (PN) is often implemented however it has not been shown to offer improvement in life expectancy or relieve symptoms of dehydration. [6] However, the reassurance this support brings to the person and family should not be discounted. [2] For people in the advanced stage of dementia medically assisted nutrition support is not recommended. [4]

Overall it is important to ensure good communication between all parties is facilitated, with the likely impact of health deterioration on eating and drinking discussed as part of the care planning and mutually acceptable nutrition support strategies agreed on, as well as when these should be discontinued. [6]

Quality Statement

Overall, the evidence is relatively weak as it is based on prospective non-controlled or qualitative studies, in the absence of randomised or controlled trials. However, these may be the most appropriate on which to base practice as an RCT design can be challenging to complete in this population.
 

Page updated 22 June 2021

 

  • References

  • About PubMed Search

  1. Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J. Medically assisted nutrition for adult palliative care patients. Cochrane Database Syst Rev. 2014 Apr 23;(4):CD006274.
  2. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017 Feb;36(1):11-48. Epub 2016 Aug 6.
  3. French Speaking Society of Clinical Nutrition and Metabolism (SFNEP). Clinical nutrition guidelines of the French Speaking Society of Clinical Nutrition and Metabolism (SFNEP): Summary of recommendations for adults undergoing non-surgical anticancer treatment. Dig Liver Dis. 2014 Aug;46(8):667-74. doi: 10.1016/j.dld.2014.01.160. Epub 2014 May 1.
  4. Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, et al. ESPEN guidelines on nutrition in dementia. Clin Nutr. 2015 Dec;34(6):1052-73. doi: 10.1016/j.clnu.2015.09.004. Epub 2015 Sep 25.
  5. Gent MJ, Fradsham S, Whyte GM, Mayland CR. What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ Support Palliat Care. 2015 Sep;5(3):223-31. Epub 2014 Mar 17.
  6. Del Rio MI, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, et al. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psychooncology. 2012 Sep;21(9):913-21. Epub 2011 Dec 8.
 
 

Nutrition / Malnutrition

("Nutritional Status"[Mesh] OR "Nutrition Therapy"[Mesh] OR "Nutrition Disorders"[Mesh] OR nutrition*[tiab] OR malnutrition[tiab] OR undernourish*[tiab] OR under nourish*[tiab] OR undernutrition[tiab] OR under nutrition[tiab] OR malnourish*[tiab])