Hydration and Nutrition at End of Life

1. Hydration and Nutrition at End of Life Chelsa Marcell, RD Registered Dietitian, Clinical Nutrition Concordia Hospital

2. Definition Food is any substance or material eaten to provide nutritional support for the body or for pleasure. It usually consists of plant or animal origin, that contains essential nutrients, such as carbohydrates, fats, proteins, vitamins or minerals, and is ingested and assimilated by an organism to produce energy, stimulate growth, and maintain life. Wikipedia, 2010

3. Definitions continued End-of-life care for seniors requires an active, compassionate approach that treats, comforts and supports older individuals who are living with, or dying from, progressive or chronic life-threatening conditions. Such care is sensitive to personal, cultural and spiritual values, beliefs and practices and encompasses support for families and friends up to and including the period of bereavement. �A Guide to End-of-Life Care for Seniors� (2000)

4. Definitions continued: End of life, for purposes of this presentation, will refer to both: the final days of life the final stage of life, which may last for weeks to months.

5. Definitions continued: Artificial nutrition (nutrition support) is any non-oral means of administering nutrition. Intravenous - Total parenteral nutrition (TPN) Enteral - Tube feed Routes � Nasoenteric = NG, ND, NJ - Enterostomy = gastrostomy, jejunostomy = PEG, PEJ, PEG-J

6. Definitions continued: Artificial Hydration (rehydration therapy) involves the non-oral delivery of fluid via one of the following routes: intravenous (peripheral or central line) subcutaneous (hypodermoclysis) rectal enteral (gastrointestinal tract)

7. Emotional Aspects of Eating Food and drink have social meaning and are equated with nurturing/caring. Provides an opportunity to meet/gather whether for cup of coffee or large celebration Family may find it difficult to see/accept that their loved one is consuming less. Family may struggle with balancing �comfort care� with concerns of death by �starvation�. Food is more than nutrition; it plays an important role in maintaining hope.

8. Poor Oral Intake � Dietitian Consult Regional criteria for when to consult dietitian embedded into consult form Copy of Criteria also in Diet Compendium on nursing unit Weight & Height added

9. Poor Oral Intake � Dietitian Assessment WRHA Acute Care Nutrition Assessment Most often used for initial nutrition assessments Located under lilac �Allied Health� tab (or �Consult� tab if no Allied Health tab) 2 pages (with carbon copy) Page 1 � includes data collected about patient necessary to make an assessment Page 2 � includes nutrition assessment, Nutrition Diagnosis, intervention, monitoring/evaluation details Follow-up assessments� usually documented in IPN but may use 2-page form above if patient health status and/or direction of nutrition care has changed significantly.

10. Poor Oral Intake � Dietitian Assessment Some common interventions/recommendations include: High calorie/protein diet Texture modifications (if dysphagia, consult SLP) Food preference/dislikes update, modify portion size Add nutritional supplements and/or snacks Lab workup � prealbumin, iron studies, B12 Vitamin and/or mineral supplementation Nutrition education/counselling (? patient understand/accept nutrition interventions recommended) Liberalize diet if currently restrictive Mealtime assistance by unit staff � assess patient alertness, tray setup, help with feeding, encouragement, proper body positioning, modify environment (lighting, limit distractions, proper table height), wearing dentures/eyeglasses Request medication review Calorie counts, weight measurements

11. Poor Oral Intake � Dietitian Assessment Once all options to maximize nutrient intake orally have been exhausted, treatment decisions need to be made regarding the goals of care and direction of future nutrition care interventions. Options: Comfort feedings � as long as it is not distressing, allow patient to determine the amount and type of intake. Comfort is goal of feeding. Nutrition Support (TF or TPN) � prior to offering NS as a treatment option or proceeding with NS that patient/family has requested, team must have physician approval/order to do so. Considerations: 1. What is patient prognosis? What are goals of care? 2. If patient survives, will quality of life remaining be acceptable to patient? 3. Do benefits outweigh potential discomfort, pain and risks? 4. What does/would patient want?

12. Poor Oral Intake � Dietitian Assessment If Patient Competent - would want patient to decide If Patient Not Competent � ? Health-Care Directive - Substitute Decision-Maker * Team meeting with Family +/- Patient to discuss Nutrition Support option and review resource. ** Respecting autonomy, by honoring patients decision/wishes, can be difficult for family/staff.

13. WRHA Enteral Nutrition Resource