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Nutrition

Key Messages

  • Decreased oral intake and weight loss is normal for palliative patients. [1]
  • Focus of nutrition support should be for quality of life only. [2]
  • Enteral and Parenteral nutrition is not generally recommended in palliative care. [3]
  • Artificial hydration may exacerbate medical symptoms while not relieving symptoms of dehydration. [4]
  • It is important to consider cultural significance and symbolic value of artificial hydration to the patient and family. [4]
  • Ultimately the clinical decision regarding artificial nutrition or hydration is the responsibility of the medical team. [5]

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. However, in palliative care, the goal may become to optimise quality of life through food, rather than the attainment of adequate nutritional intake. Controversy can occur around when to provide nutrition support, when it should be discontinued, and who makes this decision. 
This summary discusses the role of nutrition support in palliative care. 


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 patient 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. [4] 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. [5] 


While a number of strategies can be implemented for nutrition support, the goal remains symptom management and enjoyment of food. 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, assisted nutrition therapy such as enteral or parenteral nutrition has not been shown to offer improvement in life expectancy or relieve symptoms of dehydration. [5] However the reassurance this support brings to the person and family should not be discounted.


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. [5]

 

Quality Statement

Overall the evidence is relatively weak as they are 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 created 01 May 2017

 

  • 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. Senesse P, Bachmann P, Bensadoun R-J, Besnard I, Bourdel-Marchasson I, Bouteloup C, et al. 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. Epub 2014 May 1.
  4. 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.
  5. Rio M, 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])