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Hydration and Nutrition

at the End of Life

You matter because you are you. You matter to last moment of
your life, and we will do all we can, not only to help you die
peacefully but to live until you die
Dame Cicely Saunders

Background

In dying process HYDRATION OR NOT

HYDRATION is challanging, needs


indivudulized approach

In terminally ill patients, unwanted nutritional support


and hydration through IV or enteral routes may not
only be ineffective in reducing morbidity, but may
even be associated with an increase in medical
complications and reduction in QoL. (Mc Cann:
JAMA, vol 272, October 1994)

Does not change metabolic abnormality of cachexia


Does not improve survival, tumor response, tolerance to

anticancer, qOL

End-of-life care program


Aim for
Choices for patients to have a quality of death:

peace, comfort and dignity


Effective care planning :assess patient care needs
and preferences, support the family in LETTING HIM
GO
fewer emergency admissions
fewer transfers to hospital

Various attitudes toward dying and death

ARTIFICIAL HYDRATION AND


NUTRITION IN END OF LIFE: is it
Nonmalifience or harmful ? Beneficial or
burden?

Artificial nutrition and hydration


Parenteral:

IV : peripheral, central
SC : hypodermoclysis
Enteral

NGT
Gastrostomy
Rectal: Proctoclysis

Current Conditions

Most patients are in IV hydration and nutrition (until

the nurses give up finding the vein) or on NGT


IV hydration/TPN or NGT creates distress

Provision of food and fluid: whose problem?

Literature review:
Most terminally ill cancer patients decrease or cessation
of oral intake
Risk of dehydration:
a. Decreased /cessation of oral intake:
b. Increased water losses

AHN are traditionally considered useful and necessary components


of good medical care.
When a person is approaching death, the provision of AHN:
potentially harmful and may provide little or no benefit to the
patient
may make the period of dying more uncomfortable for both the
patient and family.
The AAHPM believes that the withholding of AHN near the end
of life may be appropriate and beneficial medical care.
Clinical judgement and skill in assessment of individual clinical

situations is necessary to determine when AHN are appropriate


measures to apply.

Symptoms of thirst and hunger in terminal illness

Is IV REDEHYDRATION NECESSARY?
Hunger, thirst, dry mouth could be eleviated with small amount

of food, fluids and/or by the application of ice chips and


lubrication to the lips.
CULTURAL APPROACH

Evidence base in PC
NGT and PEG do not produce prolongation of life & tumor

response
N/GTs can cause abdominal distention & cramps, vomiting,
diarrhea, dyspnea and aspiration pneumonia.
IV: Hospitalization, Regular monitoring, Cost
Waller A et al, 1994: 1-2 l/day: more abnormal sodium, urea,
osmolarity
Fainsenger R et al, 94: hydration related to a better symptom
control
Bruera E et al, 2000: hydration results in decreased myoclonus
and sedation, but not hallucination
Edmenton PC Canada routine use of hydration to reduce
confussion and delirium, and accumulation of opioid metabolites
which induce myoclonus and confussion.

Dietary requirement
The simpler the advice the better
Explain to the family:
Do not force the patient to eat: discourage he must eat
or he will die
Balance diet is unnecessary, ristriction?
FOOD IS LOVE AND FEEDING HIM IS MY JOB
Eat small frequent meals, smaller plate, well served
What the patient want,
When the patient want,
Where the patient feel comfortable: dining room, dress
well

Anorexia
Activity, exercise
Food serving: tasty, visually appealing,

free of odor, room temperature, easy to


digest, high calories, small portion< free
garlic and onion
Eat in sitting position
Appetite stimulant:
antihistamin
prokinetic agent
corticosteroid
progestogen

Dysphagia
Avoid large meals, carbonated drink, alcohol
Small meals, soft moist food, blendered food
Maximize calories: cream soup,
Dry mouth: drug evaluataion, ice chips, chewing gums,

artificial saliva
Liquid may more difficult to swallow
Small amount of food place towards the back of the mouth

Tips for dysphagia


Posture: sitting comfortably, head upright
RELAX: calm frame of mind
DO NOT TALK
YAWN: ease the constriction
Feeding routine:

small routine...close
lips...chew...pause...purposeful swallow..pause
TAKE TIME
After meals: drink small amount of water: rinse the
mouth and clear throat
SIT: remain sitting half an hour

Stomatitis
Avoid spicy, acid, sharp food and carbonated

drinks
Drink through a straw

HEART BURN
Wear loss garment
Elevate bed 10 cm

Abnormal taste
Tart food: pickles, vinegar, lemon juice
Add or reduce sugar
White meat, eggs, diary product
Bitter taste: more seasoning, room

temperature, drink more, marinated


meat

Constipation

Increase food intake


Add bran to diet
Increase fluid
Fruits and vegetable
Increase mobility

Bowel obstruction

Drink to relieve thirst


High calories: ice cream
Stop solid food: chew n spit it out
IV/SC Infussion

Indication of TPN
Chronically obstructed patients
Life expectancy of over two months with malnutrition

caused by starvation rather than by tumor


progression
Absence or good control of major symptoms not
related to nutrition
No tumor involvement in vital organ (brain, lung, liver)
Median survival 3 months, 25-30% 6 months

Indications of SC infusion
Mild/moderate dehydration
Impaired IV access
Community care

Contraindication
Severe dehydration
Poor tissue perfussion
Infection /broken skin
Increased risk of pulmunary cangestion/oedema
Clotting disorder
Preexisting oedema

IV line +
do not over hydrate (balance?)
regular evaluation
If IV canule fails, consider not to replace

IV line - COMFORT

Sips
Ice chips
Regular mouth care
Artificial saliva

SC HYDRATION