Webinar presented by VITAS Healthcare on November 10, 2016. Presented by Barry M. Kinzbrunner, MD

1. Nutritional Support and
Hydration for Patients Near
the End of Life
Developed by
Barry M. Kinzbrunner, MD
Chief Medical Officer
VITAS Healthcare
Miami, FL

2. Objectives
• Examine how the cardinal ethical values impact
decision-making regarding nutritional support
and hydration at the end of life
• Review the pathophysiological mechanisms that
result in an altered nutritional status and altered
hydration as patients near the end of life
• Summarize the data in the medical literature
regarding nutritional support and hydrational
support for patients near the end of life

3. Nutrition & Hydration:
Ethical Questions
• Do patients/families have a right to demand
or refuse artificial food/fluid?
• May artificial feedings/hydration be withheld?
• May artificial feedings/hydration be withdrawn?
• May health care facilities deny care based on
a patient/family decision regarding artificial
nutrition/hydration?

4. Cardinal Principles of
Medical Ethics
Principle Definition
Autonomy Self-determination by choosing among
available treatment options
Beneficence Taking action for the patient’s benefit
Non-maleficence Avoiding harm
Justice:
Societal
Distributive
Doing what is good for the society as a whole
Allocating resources wisely
Kinzbrunner BM: Introduction in Kinzbrunner BM,
Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. xvii.

5. Nutrition & Hydration:
Autonomy
• Patients/families have a right to choose whether
or not to receive artificial nutrition or hydration
– Social reasons
– Religious reasons
• Health care providers and facilities have a right to
set policies as to whether they want to care for
patients who decline artificial feeding/hydration

6. Nutrition & Hydration:
Beneficence
Belief that artificial nutrition and hydration:
• Improves nutritional status
• Reduces aspiration pneumonia risk
• Assists in healing of decubitus ulcers
• Improves functional status
• Reduces hunger and thirst

7. Nutrition & Hydration:
Non-Maleficence
Belief that artificial nutrition and hydration:
• Reduces aspiration pneumonia risk
• Is a low risk procedure to the patient
• Reduces hunger and thirst

8. Nutrition & Hydration:
Justice
Social Justice
• Society has an obligation to protect citizens
who are unable to take of themselves
• Society should not deny basic care to
individuals based on their mental status
or other medical conditions

9. Nutrition & Hydration:
Justice (Cont.)
Distributive Justice
• Ability to provide skilled vs. unskilled care
• Cost of artificial feeding
– Procedure, pump, formula all reimbursable services
• Spoon feeding with an attendant
– Labor intensive which is not reimbursable

10. Nutrition Near the End of Life
Cancer anorexia-cachexia syndrome
• Metabolic abnormalties
– Carbohydrate metabolism
• Insulin resistance
• Glucose intolerance
– Lipid and protein metabolism
• Gluconeogenesis from lipid and protein sources
• Humoral mediators
– Tumor necrosis factor
– Interleukins
– Gamma interferons
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 569.

11. Nutrition Near the End of Life
(Cont.)
Direct effects of tumors & antineoplastic therapy
• Abdominal fullness
• Taste change
• Dry mouth
• Constipation
• Uncontrolled nausea and emesis
• Dysphagia
• Mechanical obstruction
• Uncontrolled pain
Sihra L, Kinzbrunner BM: Artificial Nutrition
and Hydration in Kinzbrunner BM, Policzer JS
(eds): End-of-Life Care: A Practical Guide.
New York: McGraw Hill, 2011, p. 569.

12. Nutrition Near the End of Life
(Cont.)
Anorexia in the debilitated patient
• Impaired mobility
• Impaired cognition
• Modified consistency diets
• Upper extremity dysfunction
• Abnormal oral and pharyngeal function
• Impaired dentition, ill-fitting dentures
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 571.

13. Treatment of Malnutrition
• Parenteral nutritional support
– Total parenteral nutrition (TPN)
• Enteral nutritional support
– Oral supplementation with or without dietary counseling
– Gastrointestinal intubation
• Nasogastric tube
• Percutaneous endoscopic gastrostomy
• Operative gastrostomy
• Pharmacologic interventions
• Non-pharmacologic interventions

14. Parenteral Nutritional Support
Analysis of 12 prospective randomized trials
evaluating the use of TPN in patients receiving
chemotherapy
•Rate of infection:
– Increased in TPN patients in 4/6 studies
(2 with no difference, 6 did not report)
•Survival:
– Decreased in TPN patients in 2/9 studies
(7 with no difference, 3 did not report)
•Tumor response
– No difference in 9/9 studies (3 did not report)
Klein, S. Clinical efficacy of nutritional support in patients with
cancer. Oncology: 7(11,suppl), 87-92, 1993.

15. Parenteral Nutritional Support
(Cont.)
American College of Physicians Position Paper
Parenteral Nutrition in Patients Receiving Cancer
Chemotherapy
“…(T)he evidence suggests that parenteral nutrition
support was associated with net harm, and no conditions
could be defined in which such treatment appeared to be
of benefit. Thus, the routine use of parenteral nutrition for
patients undergoing chemotherapy should be strongly
discouraged….”
American College of Physicians. Parenteral Nutrition in Patients
Receiving Cancer Chemotherapy. Ann Int Med 110:734, 1989.

16. Enteral Nutritional
Support—Oral
Terepka and Waterhouse, 1956
Metabolism of force-fed patients with cancer
• Nine patients with progressive cancer
• Weight gain secondary to intracellular fluid retention
• Early retention of nitrogen and phosphorus
• Subsequent return of negative nitrogen balance
• Half the patients had detrimental effects from
forced feeding
Terepka AR, Waterhouse C: Metabolism of force-fed patients
with cancer. Am J Med 20:225, 1956.

17. Enteral Nutritional
Support—Oral (Cont.)
Ovesen, Allingstrup, Hannibal, et al, 1993
Effect of dietary counseling…in cancer patients
undergoing chemotherapy
•Randomized trial
•Responsive malignancies
– Small cell lung caner
– Breast cancer
– Ovarian cancer
•No significant response or survival advantage found between
group that received dietary counseling and control group
Ovesen L, Allingstrup L., Hannibal J., et al: Effect of dietary counseling on food
intake, response rate, survival, and quality of life in cancer patients undergoing
chemotherapy. A prospective randomized trial. J Clin Oncol 11:2043,1993.

18. Enteral Nutritional
Support—Tube
Gastrostomy vs. NG-tube
• % of prescribed intake
– G-tube 93%; NG-tube 55% (p < 0.001)
• Reasons for failure
– G-tube (0/19)
– NG-tube (18/19)
• Failure to position
• Displacement of tube
• Patient refusal
Park, RH, Allison, BC, Lang, J, et al: Randomized comparison of
percutaneous endoscopicgastrostomy and nasogastric tube feeding patients
with persisting neurological dysphagia. Br Med J 304:1406, 1992.

19. Enteral Nutritional Support—
Tube (Cont.)
Efficacy of Tube Feedings
. 95.4 95
75.7
62
2.3 2.5
6 5
2.3 2.5
18.3
33
0
20
40
60
80
100
< 1 mo 1-2 mo 2-6 mo 6-11 mo
Duration of tube feeding, months
%Patients
Stable Weight
Weight Gain
Weight Loss
Ciocon JO, Silverstone, FA, Graver LM, Foley CJ: Tube
feedings in elderly patients. indications, benefits, and
complications. Arch Int Med 148:429-433.

20. Enteral Nutritional Support—
Tube (Cont.)
Patients with dysphagia 2° motor neuron disease
Tube feeding vs. conservative management
• No significant difference in age of death or median
or mean survival
• Significant differences in problems with secretions
– NG = 13/13
– Conservative mgmt = 8/18 (p < 0.01)
Scott AG, Austin HE: Nasogastric feeding in the mangement of
severe dysphagia in motor neurone disease. Pall Med 8:45, 1994.

21. Enteral Nutritional Support—
Tube (Cont.)
Mortality in Gastrostomy Patients
Indication Mortality Rate % Mortality
Neurologic debilitation 19/67 28%
Head and neck cancer 2/16 12%
Metastatic cachexia 3/8 37%
Pulmonary cachexia 9/10 90%
Postoperative inanition 1/2 50%
Total 34/103 33%
Stuart SP, Tiley EH, Boland JP: Feeding gastrostomy: A critical review
of its indications and mortality rate. South Med J 86:169, 1993.

22. Tube Feeding in Patients with
Dementia: A Review of the
Evidence
Review of published evidence regarding benefits of
tube feedings:
•No reduction in aspiration pneumonia risk
•No effect on clinical markers of nutrition
•No improvement in patient survival
•No improvement or prevention of decubitus ulcers
•No reduction in infection risk
•No improvement in functional status or slowing of decline
•No improvement in patient comfort
Finucane TE, Christmas C, Travis K: Tube feeding in patients
with advanced dementia. J Am Med Assoc 282:1365, 1999.

23. Review of published evidence regarding
harmful effects of tube feedings:
•Mortality
– Perioperative mortality 6-24%
– 30 day mortality 2-27%
– One year mortality > 50%
•Aspiration 0-66% Local infection 4-16%
•Occlusion 2-34% Leaking 13-20%
•2/3 of NG tubes require replacement
Finucane TE, Christmas C, Travis K: Tube feeding in patients with
advanced dementia. J Am Med Assoc 282:1365, 1999.
Tube Feeding in Patients with
Dementia: A Review of the
Evidence (Cont.)

24. Pharmacologic Interventions
Medication Dosage
Steroids
Dexamethasone 1.5-4 mg qd to qid
Methylprednisolone 20 mg qd to qid
Prednisone 20 mg qd to qid
Megestrol acetate 160-400 mg bid
Metoclopramide 10 mg tid ac and hs
Tetrohydrocannibinol (THC) 2.5 mg tid
Cyproheptidine 4 mg tid
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 573.

25. Pharmacologic
Interventions (Cont.)
Steroids
• Improve appetite in 50-75% of patients with cancer
• Effects within days
• Maximum effect within four weeks
• Effects fade over time
• Side effects
– Oral thrush
– Edema and cushingoid features
– Dyspepsia
– Psychic changes
– Ecchymoses
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 573.

26. Pharmacologic
Interventions (Cont.)
Megestrol Acetate
• Effects on appetite and food intake
• Less clear effect on body weight
• Possible improvement in quality of life
• Minimum effective dose 160 mg/day
• Maximum effective dose 800 mg/day
• Requires minimum of 2-3 months for effect
• Should not be started on patients with prognoses of
several weeks or less
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 573.

27. Pharmacologic
Interventions (Cont.)
Metoclopramide
• Increases lower esophageal sphincter pressure
• Effective for symptoms related to delayed
gastric empyting
• Will cause increase in symptoms in patients with
gastric outlet obstruction
• Extrapyramidal side effects
– Reversed with benadryl
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 574.

28. Pharmacologic
Interventions (Cont.)
Tetrahydrocannibinol
• Primarily studied in HIV patients
• Stimulation of appetite and mood, some weight gain
• 2.5 mg tid
• CNS toxicity (especially in elderly)
– Dizziness
– Somnolence
– Disassociation
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 574.

29. Pharmacologic
Interventions (Cont.)
Cyproheptadine
• Borderline appetite stimulation compared to placebo
• No weight gain
• Increased somnolence and dizziness
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 575.

30. Non-pharmacologic
Interventions
• Assess for treatable causes
– Oral thrush
– Nausea and emesis
– Metabolic disturbances
• Dietary counseling to adjust eating habits
– Smaller plates and portions
– Eat whenever desired
– Lift dietary restrictions (i.e. low salt, ADA)
– Allow favorite foods
– Avoid strong smells, spices, hot foods
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 576.

31. Non-pharmacologic
Interventions (Cont.)
• Dietary counseling to explain changing dietary
needs to patient and family
– Need for less food
– Lifting of dietary restrictions
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration
in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A
Practical Guide. New York: McGraw Hill, 2011, p. 576.

32. Studies on Hunger at
the End of Life
32 patients: recorded food and water ingestion
Degree of
Hunger
# Pts (%) Normal
Intake
Reduced
Intake
Liquids Only
None 20 (63%) 0 18 2
Present initially 11 (34%) 0 8 3
Present until
death
1 (3%) 1 0 0
Total 32 (100%) 1 26 5
McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients.
The appropriate use of nutrition and hydration. J Am Med Assoc 272:1263, 1994.

33. Studies on Hunger at the
End of Life (Cont.)
Modification of nutritional behavior
116 elderly patients with terminal cancer
• Patient food preferences
• Patient dislikes
• Subjective intolerance to certain foods
• Difficulties chewing or swallowing
Feuz A, Rapin CH: An observational study of the role of pain
control and food adaptation of elderly patients with terminal
cancer. J Am Dietetic Assoc 94:767, 1994.

34. Studies on Hunger at the
End of Life (Cont.)
Modification of nutritional behavior
Results:
•107 patients (92%) had meals until the day
of death
•Nine patients (8%) stopped eating an
average of 3.5 days before death
•51 patients (44%) remained on the diet
plan established at first visit
Feuz A, Rapin CH: An observational study of the role of pain
control and food adaptation of elderly patients with terminal
cancer. J Am Dietetic Assoc 94:767, 1994.

35. Symptoms of Hydration
Near the End of Life
Symptom Occurrence Treatment
Thirst Common Oral fluid, ice chips
Dry mouth Common Meticulous mouth care
Artificial saliva
Nausea & emesis Rare Symptomatic Rx
Headache Not reported
Cramps Not reported
Postural hypotension Occasional Parenteral hydration may be
indicated
Lethargy Common but w/o
distress in
bedbound pts
May protect against pain and
other discomforting
symptoms in bedbound ptsDrowsiness
Fatigue
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 579.

36. Studies on Symptoms
of Dehydration
• Collaud et al: J Pain Symp Manag, 6:230, 1991
– Physician assessment of importance of
symptoms of dehydration
• Dryness of mouth: 88% serious
• Thirst: 40% serious
• Overall suffering: 38% serious
• Phillips et al: N Eng J Med 311:753, 1984
– Elderly experience reduced thirst after water
deprivation when compared to young

37. Studies on Symptoms
of Dehydration (Cont.)
• Burge: J Pain Symp Manag 8:454, 1993
– VAS assessment of symptoms of dehydration
– Pleasure in drinking: 70/100 (avg); 40-80 (range)
– Fatigue: 70/100; 40-90 Dry mouth: 55/100; 50-90
– Bad taste: 50; 15-75 Thirst: 50; 30-80

38. Effects of Hydration Near
the End of Life
Adapted from Rousseau P: How fluid deprivation
affects the terminally ill. RN:54, 73, 1991.
Organ System Effect of Hydration
Renal Increased urinary output
Increased need for catheter
Increased infection risk
Pulmonary Increased pharygeal & lung secretions
Increased dyspnea, cough, congestion
Increased risk of pulmonary edema
Gastrointestinal tract Increased GI fluid output
Increased risk of nausea & emesis
Other body
compartments
Increased per-tumor edema
Increased peripheral edema

39. Hydration Near the
End of Life
Common Methods of Delivery
of Fluids
•Intravenous
– Peripheral IV
– Central access port
when available
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 579.

40. Hydration Near the
End of Life (Cont.)
• Hypodermoclysis
– Subcutaneous infusion
– 24-25 gauge Teflon catheter
– Approximately 1 liter/day maximum
– Hyaluronidase 150 units/l
• Enzyme that breaks down interstitial barriers in
subcutaneous space
• Promotes fluid absorption
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 581.

41. Hypodermoclysis
Symptom-related medications that can be administered
via this route
•Pain
– Morphine – Hydromorphone
•Sedation & other CNS symptoms
– Midazolam – Haloperidol
– Phenobarbital – Dexamethasone
•Gastrointestinal
– Metoclopramide
•Respiratory secretions
– Atropine – Scopolamine
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 581.

42. Hypodermoclysis (Cont.)
Potential indications for hypodermoclysis
in patients near the end of life
•Poor oral pain control
•Dysphagia
•Severe emesis
•Bowel obstruction
•Confusion
•Requirement for parenteral medication
•Cultural or religious need
Bruera E, Brenneis C, Michaud M, et al: Use of the subcutaneous
route for the administration of narcotics in patients with cancer
pain. Cancer 62: 407, 1988.

43. Studies on Hydration at
the End of Life
• Bruera et al: J Pain Symp Manag 1:287, 1995
– Relief of delirium
• Waller et al: Am J Hosp Pall Care: 11(4), 26, 1994
– No difference in level of consciousness between
patients who did and did not receive parenteral
hydration

44. Symptoms of Thirst at
the End of Life
32 patients: recorded food and water ingestion
Degree of
Thirst/Dry
Mouth
# Pts (%) Normal
Intake
Reduced
Intake
Liquids Only
None 11 (34%) 0 8 3
Present
initially
9 (28%) 0 9 0
Present until
death
12 (38%) 1 9 2
Total 32 (100%) 1 26 5
McCann RM, Hall WJ, Groth-Juncker A: Comfort care for
terminally ill patients. The appropriate use of nutrition and
hydration. J Am Med Assoc 272:1263, 1994.

45. Studies on Hydration at
the End of Life (Cont.)
2005: Randomized Clinical Trial
• 1000 cc/day of parenteral fluid
vs. placebo of 100 cc/day over 4 hours
• 51 Patients were studied for two days
• Symptoms evaluated: hallucinations,
myoclonus, fatigue, sedation, global well-being
and overall effectiveness
• Investigators were also asked to rate global
well-being and overall effectiveness
Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in
terminally ill cancer patients; A preliminary study. J Clin Oncol 23:2366,
2005.

46. Studies on Hydration at the
End of Life (Cont.)
Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally
ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.

47. Studies on Hydration at the
End of Life (Cont.)
Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally
ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.

48. Studies on Hydration
at the End of Life (Cont.)
2005: Randomized Clinical Trial
Conclusions
•Parenteral hydration decreases some symptoms
associated with dehydration (myclonus and sedation)
•Hydration was well-tolerated
•Definite placebo effect observed
•Further studies involving a larger number of patients
with a longer follow-up period are warranted
Bruera E, Sala R, Rico MA, et al: Effects of parenteral hydration in terminally
ill cancer patients; A preliminary study. J Clin Oncol 23:2366, 2005.

49. Conclusions
Principles for providing nutritional support and
hydration for patients near the end of life
•Individualize decision making based on the
“Principles of Medical Ethics”
•Consider correctable causes of decreased oral intake
and provide appropriate interventions when indicated
•Prioritize to non-invasive followed by least invasive
methods of delivery
•Tailor amount of food and fluid in such a way as to
minimize side effects and toxicities
Sihra L, Kinzbrunner BM: Artificial Nutrition and Hydration in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 583.

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