nutrition recomendations

2. Nutrition, Eating, and Palliative Care
Ted St. Godard MA MD

3. “Let food be your medicine and let
medicine be your food.”
Hippocrates
“Sex is good, but not as good as fresh,
sweet corn.”
Garrison Keillor

4. I. Psycho-social aspects of eating and not eating
 “starving,” “wasting,” some patients
II. Approach to patients and families
III. Nutrition challenges in the gravely ill
IV. Cachexia versus Starvation (? Decreased PO =
starvation)
V. Role for Artificial Nutrition
 Yes, no, maybe so?
VI. “Palliative Perspective”

5. “Nothing would be
more tiresome than
eating and drinking
if [they were not] a
pleasure as well as
a necessity.”
Voltaire

6. Meals/eating highly “loaded”
celebrations, milestones, happy
times, sad times, memories
Many or most patients with terminal
illness ultimately are unable to eat
enough to avoid weight loss and
maintain activity levels

7. Patients
Body image? Sexuality?
Embarrassment, shame, guilt,
frustration
Weaker and weaker, smaller and
smaller
“I’m wasting away…”

8. Families
Frustration, anger
LO weaker, smaller, frailer, but
“won’t eat”
Try harder, vicious circle
Conflict
“We can’t just let her/him starve…”

9. “Starvation”
We live in a world where this ought
not to happen
Unconscionable
“Wasting”
Inefficient, shameful, immoral?

10. Nutrition is a basic animal need
Is feeding a fundamental component
of care? A right?

11.  38 male, metastatic esophageal Ca.
 Presented with pneumo-mediastinum
 PEG
 Cachectic, ate (copiously) for months
 53 female, metastatic ovarian Ca., bowel
obstruction
 Obese, eating (copiously) around NG
 Increasing emesis… “How will we feed her
now?”

12.  73 male, metastatic hepato-cellular Ca.,
 Frail, bedbound, cachectic, icteric
 “Doctor, he no eat. Make him eat”
 53 female, metastatic breast Ca., bowel
obstruction (multiple omental mets, abd/pelvic
adenopathy)
 Looks well, ambulating
 “So now I just starve to death?”

14. Goals of Care
(Maintain quality of life; avoid prolongation of dying)

15.  WHO definition:
 Palliative care is an approach that improves
the quality of life of patients and their families
facing the problem associated with life-
threatening illness, through the prevention and
relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems,
physical, psychosocial and spiritual.

16.  WHO definition:
 …improves quality of life of patients and their
families
 ……prevention and relief of suffering
 …..early identification,… assessment and
treatment of
 …. problems, physical, psychosocial and
spiritual.

17. “Active
Treatment”
Palliative
Care

18. “Active
Treatment”
Palliative
Care

19. Cure, restore function, prolong life, provide comfort

20. Comfort always
Prolong life
Restore function
Cure

21. Failure to achieve balance
1. Decreased PO intake
 Anorexia, xerostomia, altered
taste/smell, odyno/dysphagia
2. Decreased absorption
3. Altered energy utilization

22. Inadequate ingestion
“Developed” countries: medical
reasons
Worldwide: lack of food

23. Anorexia (loss of appetite)
Multi-factorial
“Cytokines”: central (hypothalamic)
and peripheral (via vagus nerve)
influences
Huge frustration for families, source
of much tension

24. Anorexigenic
Neuropeptide
Neurotensin
Melanocortin
CRF
Orexigenic
Neuropeptide
Glucogon
CCK
Leptin
Blood Brain Barrier
NPY
AGRP
MCH Neurotensin
Melanocortin
CRF
Glucogon
CCK
Leptin
NPY
AGRP
MCH
CNS Cytokinase
Cytokinase
CNTF
IL-1
CNS Cytokinase
CNTF
IL-1
Food Intake
Energy Expenditure Food Intake
Energy Expenditure
Seratonin
Blood Brain Barrier
IL-6
Tryptophan
Glucocorticoids
ACTH
Anorexigenic
Neuropeptide
Orexigenic
Neuropeptide
IL-1
IL-6
TNF-
INF-
_
+
+
+
+
+
+
+
+
+
+
+
+
+
_
_
_
_
_
_
_
_
A B

25. Approach:
1. Symptom control (nausea, pain)
2. Meal selection, timing,
portion/presentation
3. Avoid/reduce conflict (eat, drink, be
merry): “eat what, where, when, as
much/little as you want”

26.  Progestational agents:
Megestrol
 Corticosteroids:
Dexamethasone
4. Pharmacology in anorexia Tx

27.  ?Metoclopromide
 ?Cannabinoids
 ?Melatonin (decrease TNF)
 ?NSAIDS (decrease
inflammatory mediators)
4. Pharmacology in anorexia Tx

28. Appetite stimulants may increase intake,
body weight, and quality of life, but they
do not affect prognosis in the terminally ill
Dy, M. “Enteral and Parenteral Nutrition in
Terminally Ill Cancer Patients: a Review of
the Literature.” American Journal of
Hospice and Palliative Medicine. 2006; 23
(5): 369-377

30.  Nausea
 Emesis
 Diarrhea
 Surgical/anatomical changes
3. Altered energy metabolism

31. Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics
in Geriatric Medicine. 2002; 18: 883-891
 Starvation: pure protein/energy deficiency
(under-nutrition)
 Cachexia: cytokine-induced wasting of protein
and energy stores, caused by effects of disease
 Malignancy, COPD, ESRD, CHF, AIDS, RA
 Remarkably resistant to hyper-caloric feeding

32. Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics
in Geriatric Medicine. 2002; 18: 883-891
 Biochemical markers represent nutritional status
or illness severity?
 Acute-phase cytokine response
 Strong inverse correlation between IL-2R and
albumin, pre-albumin, cholesterol, Hgb
 Common pathway to reduction in albumin, etc.
may be cytokine induction, rather than absence
of nutrients

33. Starvation Cachexia
Appetite Late suppression Early suppression
BMI Not predictive of mortality Predictive of mortality
Albumin Low in late phase Low in early phase
Cholesterol May remain normal Low
Total lymphocyte
count
Low, responds to
re-feeding
Low, no response to
re-feeding
Cytokines Little data Elevated
Inflammation Usually absent Present
With re-feeding Reversible Resistant
Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics
in Geriatric Medicine. 2002; 18: 883-891

34.  Ethical Principles
 Autonomy
 Beneficence
 Non-maleficence
 Informed consent
Beauchamp and Childress. Principles of Biomedical Ethics. New
York: Oxford University Press. 1994 (4th Ed.)

35.  Informed consent. Patient/surrogate:
 Is able to communicate consistent preference
 Understands risks, benefits, and alternatives
 “Appreciates” the information
 Uses rational thinking to arrive at decision
Beauchamp and Childress. Principles of Biomedical Ethics. New
York: Oxford University Press. 1994 (4th Ed.)

36. Nutrition is a basic animal need
Is feeding a fundamental component
of care? A right?

37.  Artificial, specialized nutritional support is no
different from any other life sustaining medical
therapy that supports bodily function, such as
antibiotics, oxygen therapy, or dialysis.
 Not offering it is ethically acceptable if benefits
do not outweigh the risks for a particular
individual.
McClave , S., Ritchie, C. “The Role of Endoscopically
Placed Feeding or Decompression Tubes.”
Gasteroenterology Clinics of North America. 2006; 35: 83 -
100

38.  There is no ethical or legal difference
between withholding a … feeding tube
versus placing the feeding tube and then
later removing it
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

39. Several Groups of Potential
Beneficiaries
1. Malignant disease
2. Acute CVA
3. Dementia
4. Neurodegenerative diseases

40.  Two Potential Benefits
1. Prolong life
2. Palliate: improve comfort, enhance
quality of life (for patients and their
care-givers/loved ones)

41. 1. Patients with Malignancies
 Despite increased nutrient delivery, trials
show disappointing results in improving
clinical outcome
 Improvements in biochemical markers
inconsistently correlate with objective
clinical benefits
Thomas, D. “Distinguishing Starvation from
Cachexia.” Clinics in Geriatric Medicine.
2002; 18: 883-891

42. 1. Patients with Malignancies
 ?survival benefit if PEG in early head
and neck cancers (tolerate treatments
better)
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

43. Dy, M. “Enteral and Parenteral Nutrition in Terminally Ill Cancer
Patients: a Review of the Literature.” American Journal of
Hospice and Palliative Medicine. 2006; 23 (5): 369-377
1. Patients with Malignancies
 Little evidence was found for benefits
from enteral or parenteral nutrition in
terminally ill cancer patients, other than
for those with mechanical
gastrointestinal tract obstruction

44. Hunger
Often not noted
Ameliorated usually with small
amounts food/drink
Dy, M. “Enteral and Parenteral Nutrition in Terminally Ill Cancer
Patients: a Review of the Literature.” American Journal of
Hospice and Palliative Medicine. 2006; 23 (5): 369-377

45. 2. Acute CVA with Dysphagia
↑ Survival
↓ Morbidity
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

46. 2. Acute CVA with Dysphagia
 RCT compared tube feeds within 7 days of
admission versus no tube feeding for more
than 7 days
 Early tube feeding associated with NS
reduction in risk of death (ARR 5.8 %)
 ↑ Survival ? offset by 4.7 % excess of
survivors who had poorer outcomes
Dennis, Lewis, Warlow, C. “Effect of Timing and Method of
Enteral Tube Feeding for Dysphagic Stroke Patients.” Lancet.
2005; 26 (365): 764 - 772

47. 3. Dementia
 34 % pts. with dementia or cognitive
impairment have PEGs
 Prevent aspiration, heal/preven skin
ulcers, prolong life
 Evidence equivocal at best on all
counts
McClave , S., Ritchie, C. “The Role of Endoscopically Placed
Feeding or Decompression Tubes.” Gasteroenterology Clinics of
North America. 2006; 35: 83 - 100

48. 3. Dementia
 Patients with dementia who are so
disabled as to stop eating have poor
prognosis even with PEG
 PEG in demented patients huge risk
factor for restraints
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

49. 4. Neurodegenerative disease
 ALS
 Cognition usually spared
 10 – 20 % 5-year survival without artificial
ventilation and nutrition
 With support, lifespan can be extended
“indefinitely”
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

50. 4. Neurodegenerative disease
 PEG in ALS
 Improves nutrition
 Makes “eating” easier (lessens fatigue)
 Decreases time spent feeding
 Allays fears of choking
 ? Improved QOL
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

51. 4. Neurodegenerative disease
 PEG in ALS
 Mortality benefit?
 Survival increased only in patients where
PEG inserted early
 FVC < 50 % predicted increases risk
mortality
Ganzini, L. “Artificial Nutrition and Hydration at the End of Life:
Ethics and Evidence.” Palliative and Supportive Care. 2006; 4:
135 - 143

52.  Several Groups of Potential Beneficiaries
1. Malignant disease
2. Acute CVA
3. Dementia
4. Neurodegenerative diseases
 Two Potential Benefits
1. Prolong life
2. Palliate: improve comfort, enhance quality of
life (for patients and their care-givers/loved
ones)

53. Issues surrounding eating and
nutrition come to play a very
significant role in the lives of people
with most end stage illnesses
Often more difficult for families than
patients
Potential source of much conflict

54.  Decreased PO intake, and altered ability to
metabolize nutrients effectively is
etiologically complex
 Depending on goals of care, there
sometimes is a role for medication and/or
artificial nutrition
 “Treatment” must always and everywhere
take into considerations of goals of care

55. Edible: “Good to eat
and wholesome to
digest; as a worm to a
toad, a toad to a snake,
a snake to a pig, a pig
to a man, and a man to
a worm.” Ambrose Bierce