Nutritional care & Hydration in oncology and Palliative care.

1. Nutrition and Hydration in
Palliative Care
Is Nutrition Support needed / justified in
Palliative Care ???

2. The meaning of “Food”
Any nutritious substance that people or animals eat or drink
or that plants absorb in order to maintain life and growth.
It gives us the energy and nutrients to grow and develop, be
healthy and active, to move, work, play, think and learn.

3. Tradition / culture

4. Love / nurture

5. Socialization

6. • Comfort food is food that provides a nostalgic or
sentimental value to someone.
• Food that provides consolation or a feeling of
well-being, typically having a high sugar or
carbohydrate content and associated with
childhood memories or home cooking.
Psychological/ Comfort

7. What happens during Terminal Illness?

8. Terminal illness can alter the nutritional status of the patient in many ways:
• Gastrointestinal absorption ↓
• Nutrient requirements ↑ (malabsorption, cachexia and increasing tumour
mass)
• The dying process ↓ gastric emptying. (Increased satiety, decreased hunger
and food intolerances)
• Nausea, vomiting, diarrhoea and constipation. (Side-effects of Medication)
- Depression causes anorexia (Holland et al, 1977)
- Anger and guilt when present have a negative impact on dietary
intake.

9. Anorexia and Cachexia
• Anorexia : The absence or loss of appetite for food is common in
patients with advanced cancer and other chronic illnesses.
• Cachexia : Weight loss, anorexia, weakness and asthenia causing
reduced performance status, fatigue, metabolic alterations and
reduced quality of life.
• Cachexia is an inflammatory process associated with cytokine excess.
• Weight loss secondary to cachexia is often refractory to therapeutic
intervention and nutritional support.

11. The metabolic consequences of cancer are listed below
(Stratton et al 2003):
• Altered glucose metabolism - the tumour is inefficient in the
use of glucose
• Increased rate of glucose oxidation
• Increased rate of protein metabolism
• Decreased protein synthesis
• Increased protein breakdown
• Altered lipid metabolism.

12. WHO states that Palliative Care:
• Affirms life and regards dying as a normal process;
• Neither hastens nor postpones death;
• Provides relief from pain and other distressing
symptoms.
• Maintain/improve QOL
• Control symptoms

13. In palliative care,
Nutrition should be supportive and should
aim to optimize the management of nutrition
related symptoms, thus improving the sense of
wellbeing felt by the patient.

14. Dilemas in Palliative Nutrition Support
•Clinical
•Ethical
•Moral
Solutions
• Individuality
• Consent
• Benefits/Discomfort
• Multidisciplinary approach
• Constant follow-up

15. Patient’s Perspective:
• Disease progression
• Symptoms
• Progressive nutritional deterioration
• Weight loss
• Changes in body image
• Altered food intake
• The meaning of “Food”

16. Care giver's (Attender's) perspective:
Positive aspects:
•Hope
•Comfort
•Pleasure
Negative aspects:
• Guilt
• Fear
• Pain

17. Medical personnal
While it is accepted that nutrition cannot prolong life, it should
be recognized that optimal nutrition can enable and empower the
patient in the following ways:
• Optimizing physically strength to fulfil last or final
objectives
• To die with dignity, not of starvation
• To retain some control over the disease process - food
and feeding can be a useful focus for the patient

18. Palliative Nutrition Support
• Clinical assessment
• Symptoms
• Nutritional assessment
• Psychological attitude
• Food intake
• G.I. Function
• Life Expectancy:
• Short
• Medium
• Long
• Special needs

20. Fearon, K., Strasser, F., Anker, S. D., Bosaeus, I., Bruera, E., Fainsinger, R. L., … Baracos, V. E. (2011). Definition and classification of cancer
cachexia: an international consensus. The Lancet Oncology, 12(5), 489–495. doi:10.1016/s1470-2045(10)70218-7

21. Interventions

22. Barriers to Eating
• Difficulty chewing / swallowing
• Nausea / vomiting
• Anorexia / early satiety & Overwhelmed by portion size
• Xerostomia
• Taste and smell changes
Adapt consistency
More CHO, cool clear liquids & Anti-emetics
Food preferences, small frequent meals, high cal foods & supplements
Chewing gum, sour candy, ice chips, stews, sauces
Luke warm bland foods

23. Suggestions for improving nutritional intake
• Feed the patient when hungry
• Serve small portions of food
• Gently encourage - do not nag
• Set an attractive table, tray or plate
• Make much of meal times. Make them social and enjoyable. Remove
bedpans, vomit bowls and other similar items from the area
• Encourage a breath of fresh air prior to the meal. Take the patient
outside or open a window for a short time
• Eat outside if the weather is good enough
• The use of food supplements may or may not be appropriate here.
Source: Acreman, 2000

24. Pharmacological management
• Progesterones (megestrol acetate and medroxyprogesterone acetate) are the first-line
therapy for cancer anorexia.
Improve food intake and to a lesser extent, body weight and performance status.
Dose: -Megestrol acetate - 800 mg/day
-Medroxyprogesterone acetate - 1000 mg/day Maltoni et al.,
• Dexamethasone may be used as an appetite stimulant and to treat nausea.
Short duration of action & Side effects limit its use as an appetite stimulant.
Dose: 2-4 mg daily
• Prokinetic drugs help in anorexia due to gastric stasis. (Eg: Metoclopramide)
• Others: Thalidomide, omega-3-fatty acids, melatonin and NSAIDs

25. Oral Feeding
• Individual preferences
• “à la carte” meals (According to Menu)
• Appealing presentation
• Personalized portions
• Adapted consistency
• Diet counselling
• Flexible timetables
• Agreeable environment
• Family involvement
• Staff participation

26. Enteral Nutrition
Recommended:
• severe dysphasia
• severe anorexia
• decreased food intake
Clinical indications:
• head & neck / esophagus tumours
• inoperable fistulae
• esophageal obstructions

27. Parenteral Nutrition
Selected patients
• Inoperable intestinal obstruction
• Prolonged survival
• Risks vs. Benefits
Limited Use:
• Increased complications
• Difficulties in Home Care implementation
• Cost
• Ethical Dilemas

28. Hydration in Terminally ill
patients

29. Against
• Comatose patients don’t experience thirst
• Hydration may prolong death
• Decreased diuresis – less mobilization
• Dehydration - ↑ consciousness, suffering
• GI secretions - ↑ vomiting
• Lung secretions - ↑ coughing
• Oedema - ↑ ascites

30. In favour
• ↑ patient comfort
• Dehydration – delirium & renal failure
• Good in opioid toxicity delirium
• Good in hypercalcemia

31. Decrease thirst by:
• Keeping mouth wet
• Keeping lips lubricated
• Good oral care
• Small sips of liquids
• Sucking iced water or fruit

32. Hydration Methods
Artificial hydration should be used judiciously, so
as to allow maximum patient comfort.
• Enteral route
• Parenteral route
• peripheral
• central
• Subcutaneous route (hypodermoclysis) BEST

33. Hypodermoclysis (HDC), also known as “clysis,” is the
infusion of isotonic saline into the subcutaneous (SC)
space for rehydration or for the prevention of
dehydration.
Advantages:
• Easier access
• Easier & safer home use
•Subcutaneous sites last up to 7 days
• Easily turned off and disconnected
• Facilitates mobility

35. • In ambulatory patients
• Abdomen, upper chest above the breast, over an intercostal space and
the scapular area.
• In bedridden patients
• Thighs, the abdomen and the outer aspect of the upper arm.
• Sites to be avoided:
• Lymphoedematous / oedematous tissue, Bony prominences, Areas of
skin with a rash, broken skin, areas of inflammation or infection, Sites
of tumour, Peripheral limbs (distal to knees or elbows), Recently
irradiated skin sites.

37. Monitoring Hydration
•Urine output
•Blood pressure
•Mental status
•Subcutaneous sites (reactions/infection)
•Ensure no over-hydration

38. THANK YOU
Nutrition Support is an integral part of
Palliative Care