NUTRITIONAL SUPPORT

 Nutrition support alone does not reverse or cure a disease or injury. It is

adjunctive therapy that enables a patient to meet nutrient needs during
curative or palliative therapy.
 Guidelines are available that provide timelines for how long clinicians should
allow inadequate intake before initiating nutrition support.1 However, the
timeline for starting and stopping nutrition support in terminally ill patients is
often less clear to the clinician, resulting in angst over what is “the right thing
to do.”
 Burdens of Nutrition Support
 There are considerable data indicating that it is not beneficial to provide nutrition support
for patients with an irreversible (permanent vegetative state or advanced dementia) or
terminal (death anticipated within six months) illness.
 Seventy prospective randomized controlled trials of nutrition support in cancer patients
were reviewed and showed no clinical benefit to this patient population. Evidence suggests
that providing nutrition support can contribute to increased suffering in terminally ill
patients due to increased nausea, vomiting, bleeding, edema, pulmonary edema,
incontinence (bladder and bowel), or infections, as well as a potential requirement for
patient restraint.
 Benefits of Nutrition Support
 Nutrition support has been shown to benefit competent patients by reducing
physical deterioration, improving quality of life, and preventing the emotional
effect of “starving the patient to death. Practice guidelines for palliative care in
adults with progressive head and neck cancer reported that tube feeding
improved nutrient intake, quality of life, and fluid status.
 Location, Location, Location
 The approach to nutrition support at the end of life may differ based on where the patient
is dying. As the name suggests, an intensive care unit (ICU) is a location where intense
medical and surgical treatment is provided. Despite the lifesaving therapy that occurs in
the ICU, many deaths happen there after life-sustaining therapy is withheld or
withdrawn.14-17 A challenge for healthcare professionals in the ICU is to integrate
philosophical, ethical principles with sociological patient care and comfort.

 A long-term care or home location should be more compassionate since the caregiver
either has a longer period of time to get to know the patient or is a family member or
friend.
 Palliative vs. Hospice Care
 Palliative care provides physical symptom management, emotional support, and spiritual
comfort when no curative therapy is available or after making the decision to no longer
continue curative or life-prolonging therapies.18 The transition from curative to palliative
therapy should be a continuum of care to diminish any feeling of abandonment by the
patient and family.

 Hospice care integrates palliative care into “focus on relieving the substantial symptom
burden patients face at the end of life, as well as advanced care planning needs, existential
concerns, and family and social stressors.
 Debate Over Hydration
 Hydration’s role in the dying process has been debated. Fear of making
patients uncomfortable due to thirst encourages clinicians and families to
provide fluids to patients when oral intake is declining or artificial nutrition
has been discontinued.

 Water deprivation increases the body’s production of endogenous opiates that

create a euphoric state and has been associated with a reduction in pain.
 Religious Conflicts
 The Roman Catholic Church has exerted a tremendous influence over ethical decisions
concerning withdrawing and withholding nutrition support. There are currently two views
from the church. In 1957, in “The Prolongation of Life,” Pope Pius XII expressed the view
that the spiritual supercedes the physical, and therefore artificial nutrition and hydration are
morally optional when patients can no longer interact with the world around them. The
Catholic Bishops of Texas and other Catholic theological leaders have reiterated that it is
acceptable for nutrition support to be withheld or withdrawn from a patient in a persistent
vegetative state.
 Guidelines for Approaching
Nutrition Support
 Clinical practice guidelines for determining who should be considered for HPN have been
published and include the following:
 • The patient has the potential to benefit from PN.
 • The anticipated length of therapy is six months or longer.
 • The patient’s Karnofsky score is greater than 50.
 • The family and patient can perform the tasks required to infuse PN.
 • The home environment is safe and clean.
 • The patient is available for follow up and monitoring while receiving HPN.
 THANK YOU FOR
LISTENING!
GROUP 4
JAIRA ANN M. PLATA
EMELYN YAYON
REFERENCE: Nutrition Support at the End of Life: A Critical
Decision
By M. Patricia Fuhrman, MS, RD, LD, FADA, CNSD
Today’s Dietitian
Vol. 10 No. 9 P. 68