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NUTRITION AND HYDRATION AT END OF LIFE

NUTRITION AND HYDRATION AT END OF LIFE. Lisa Shives MD Horizon Hospice June 28, 2004 . REASONS FOR NUTRITIONAL DECLINE. Cancer Anorexia-Cachexia Syndrome Dysphagia A. Dementia B. Stroke C. Coma or PVS D. OP or Esophageal Malignancy FTT.

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NUTRITION AND HYDRATION AT END OF LIFE

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  1. NUTRITION AND HYDRATION AT END OF LIFE Lisa Shives MD Horizon Hospice June 28, 2004

  2. REASONS FOR NUTRITIONAL DECLINE • Cancer Anorexia-Cachexia Syndrome • Dysphagia A. Dementia B. Stroke C. Coma or PVS D. OP or Esophageal Malignancy • FTT

  3. DON’T FORGET UNCONTROLLED, DISTRACTING SYMPTOMS • PAIN • SOB • NAUSEA/VOMITING • DIARRHEA/CONSTIPATION

  4. ANOREXIA • Nonpharmacologic Treatments 1. Treat OP discomfort from stomatitis, e.g. candidiasis, or mouth ulcers 2. Encourage modification of eating habits A. Smaller, more frequent meals B. Lift dietary restrictions, e.g. low salt, low fat, ADA 3. Chew and Spit

  5. ANOREXIA • Pharmacologic Interventions 1. Steroids --Maximum appetite stimulation achieved within 4 weeks --Side effects 2. Megestrol Acetate (Megace) --When used at end of life, if benefits are not seen after 1 week, they are unlikely to occur later. --Some authorities recommend starting it earlier

  6. ANOREXIA 3. Metoclopramide (Reglan) --Increases gastric emptying --Also treats nausea and dyspepsia 4. THC --Few trials which have tended to be small and focused on chemo pts --Mixed results --Side effects

  7. NPO • Why do we recommend nothing by mouth? • Aspiration risk--determined by swallowing study in the hospital. In the home, ask about choking, coughing or pocketing food • Aspiration is Not a good death • Is it ever acceptable to recommend eating when a pt has known aspiration risk?

  8. ARTIFICIAL/MEDICAL NUTRITION VS EATING A FUNDAMENTAL DISTINCTION • Always keep in mind the importance of this distinction • Help families and other staff members understand this

  9. METHODS OF DELIVERING MEDICAL NUTRITION • TPN = TOTAL PARENTERAL NUTRITION RISKS: Infection, metabolic/lipid abnormalites, liver dysfunction Only used short term usually in acutely ill pts after all enteral options have been explored.

  10. METHODS OF DELIVERING MEDICAL NUTRITION • ENTERAL = Via the GI tract • NGT • PEG = Percutaneous Endoscopic Gastrostomy Preferred method; if the gut works, use it! Risks: infection, trauma of self removal, and most importantly, the risk of aspiration is NOT eliminated

  11. WITHHOLDING/WITHDRAWING NUTRITION AND HYDRATION • Conceptual Foundations of the Discussion • Commonly-evoked dichotomies 1. Withholding vs Withdrawing -Is there a difference? -Should we make a distinction? -Different perspectives: Ethicists and Courts Families Physicians

  12. DICHOTOMIESBOTH FALSE AND TRUE 2. Ordinary vs Extraordinary -Formulated by RCC in 1595 -Permits conflicting interpretations 3. Basic vs Heroic Care -Similar problem of interpretation 4. Killing (or Active Euthanasia) vs a Letting Die (or Passive Euthanasia) 5. Medical Treatment vs Caretaking

  13. Are Nutrition and Hydration Medical Treatments? • If so, are they different from other medical treatments? *Ethics *Law *Emotions *Social Mores *Ethnic/cultural differences • Should we make a distinction between nutrition and hydration?

  14. WHO DECIDES WHETHER TO WITHHOLD OR WITHDRAW? • Principle of Patient Autonomy = THE Guiding Principle in Biomedical Ethics today • What happens when patients cannot exercise their right to autonomy, that is who decides when patients do not have decision-making capacity?

  15. WHO DECIDES WHEN PATIENTS CAN’T • Living Wills • POA = Power of Attorney for Healthcare • Illinois Healthcare Surrogate Act • Principles of Beneficence and Nonmaleficence: Physician responsibility to act in the best interest of patients and, when it is not in their best interest to prolong their suffering, physicians play an important role in helping to relieve the burden on families of making the difficult decision to forgo medical treatment.

  16. WHAT DOES THE PATIENT EXPERIENCE? • Notes from Underground -Many anecdotes, self reportage, studies -This is not a mystery; we are not guessing; we know what it is like to starve. • Decreased desire for food at end of life • Importance of sips/chips/oral swabs/good oral hygiene

  17. WHAT DOES THE PATIENT EXPERIENCE? • Starvation vs Semi-starvation --Ugly terms, but families will use the term “starvation”, so be prepared. --2 Things to Stress 1. We know that semi-starvation is much more uncomfortable. 2. We believe that we are allowing patients to have a peaceful death due to their underlying terminal disease, NOT that we are “letting them starve to death”.

  18. WHAT DOES THE PATIENT EXPERIENCE? • Ketonemia and Endogenous Opioids *Euphoria *Decrease in pain • Improvement in secretions, edema, SOB • Freedom from the pain and inconvenience of IV • All the above benefits will be negated if you continue IVF, especially with glucose added

  19. COMFORT MEASURES ONLY • Simplify drug regimen -Stop all meds whose purpose is not pain or symptom control • Hospitalized Patients; Don’t forget to: -Stop IVF -Remove all IV if other routes for necessary meds are available -Stop all blood draws -DC PT/OT, Routine vitals, Monitor equipment, Respiratory Tx if it does not give symptom relief. -Lift Visitation Restrictions -Offer to call the chaplain -Always have PRN morphine available

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