Nutrition and hydration at the end of life. Hannah McLoughlin Palliative Medicine St5 Sheffield Teaching Hospitals 23rd May 2018

Transcription

1 Nutrition and hydration at the end of life Hannah McLoughlin Palliative Medicine St5 Sheffield Teaching Hospitals 23rd May 2018

2 Caveat I am not an expert! Some of this is personal opinion as this is not a black and white subject, and we have little evidence If in doubt- phone a friend Second opinion in your department Palliative medicine Gastroenterology Dietetics

3 Outline Cultural significance Refusal of care at end of life Medically assisted hydration and nutrition Case studies

4 Aims and Objectives By the end of this session learners will be able to: Explain why food and drink is important in a healthcare setting. Describe the different types of medically assisted nutrition and hydration. Start to consider the evidence when making decisions about hydration and nutrition.

5 Why is food and drink important in hospital? In small groups 5 minutes

6 Why is food and drink important? Basic human need and right Used to express ourselves Social activity Cultural significance Social expression of love and comfort Karin Nordstro m Christian Coff Ha kan Jo nsson Lennart Nordenfelt Ulf Go rman Food and health: individual, cultural, or scientific matters? 15 th March Genes Nutrition.

7 Why do patients and families place high importance on food? Control The only thing they can offer We should not take this away, offer families to come in and help in meal times Sign of health How will they get better if they are not E+D? Worrying reports from LCP review

8 Basic Care The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions making sure you provide help to those who are not able to feed themselves or drink fluid unaided. NMC guidance 2015

9 Advanced refusal of basic care The BMA uses the term basic care to cover the sorts of care primarily intended to keep patients comfortable rather than specifically to extend their lives. It includes offering them food, liquids. While they are competent, individuals may prefer to tolerate some pain or discomfort in order to remain alert but they cannot decide in advance to refuse pain relief and basic care when their competence is lost. Advance decisions and proxy decision-making in medical treatment and research. Guidance from the BMA s Medical Ethics Department. June 2007

10 Types of patients that we see Patients that can eat normally Patients that can t eat

11 Patients who are able to eat Normal for appetite to decrease in illness Smaller portions Little and often Naughty foods and things they actually like Support the patient and family if they choose not to eat Would still want to keep fluid up Squashes Hot or cold, Ice Ice pops/ice cream

12 Things that can help appetite Positioning Sat up, if possible out at a table Normalising meals, drinks Sit together, use cutlery and crockery Dentition Where are their dentures and do they fit? Don t force the issue Light exercise- make them hungry Medications Steroids (in the short term), antidepressants, hormones Alcohol

13 Medical support Assess the patient and take a proper history N+V Constipation Early satiety or fullness Mouth care and dental state Review medications Metformin, antibiotics, oral iron/magnesium,. Investigations Renal function, LFTs, Magnesium, Calcium, TFT s

14 What if the patient can t eat? Unconscious Unsafe swallow Mechanical Loss of capacity NBM Overwhelming N+V, breathlessness, fatigue, delirium

15 Clinically assisted hydration and nutrition CAH CAN

16 Clinically assisted hydration and nutrition CAH Enteral NG, NJ, RIG, PEG, PEJ fluids Rectal fluids Parenteral SC or IV fluids CAN PEG, PEJ, NG, NJ, RIG, feeds TPN (ie via IV route)

17 How do we decide when to start or stop these??? Can be very very very tricky. Ideally have spoken to the patient before and made a plan as part of their advance care planning.

18 Mick 68 years old H+N tumour PEG tube in situ and has been fed through this for 5 years Normally does his feed at home himself, 2 bags over 8 hours (or so) Meant to be NBM but E+D what he likes Always bothered by a dry mouth Admitted to the hospice for pain control? EOLC as has been clearly deteriorating at home

19 What would you do with his PEG feed? Would you let him E+D still?

20 Mick Mick deteriorates further, is very frail and can no longer manage his own PEG feed so the nurses take over Still bothered by a dry mouth Also starts to get some diarrhoea Later on that week becomes unconscious

21 What would you do with his PEG feed? How would you manage his mouth?

22 Mick Mick is now unconscious and clearly in last days of life Has started to develop respiratory secretions Has marked sacral oedema

23 What would you do with his PEG feed?

24 Where I find CAN difficult Massive stroke with a short life expectancy Bowel obstruction in well people Short gut syndrome Dementia Get a second opinion Have an exit strategy

25 Ellen 94 years old Dementia, HTN, Diverticular disease, CRF, touch of CML Lives in a NH, hoisted, non verbal, normally E+D with assistance Admitted unwell from her NH Has 5 children, one daughter who accompanies her, when doing your assessment reels off what she has eaten for the past 2 weeks in minute detail

26 Ellen Dehydrated, Na 156 (high) and septic Given IV fluid and full active treatment 48 hours later no improvement and looks to be dying and looses IV access Walk in and find her daughter stuffing a Malteaser in her mouth

27 How do you explain to relatives Take it slowly Make sure they understand the situation I.e. the person is dying I often explain in terms of a bad flu Comfort feeding? Capacity or best interest decision Still need to be awake enough to manage it Buttons Reassure that she will be assessed every day for dehydration and hunger

28 Decide to start SC fluid MDT decision The doctors often have no idea what a patient is taking in- you guys do! Decision is made each day- cannot be made in advance as the situation changes Needs to have a clear idea of what you are trying to achieve and when you would stop This has to be explained to family!

29 How to give SC fluid In Sheffield we only give SC normal saline Dextrose is irritant to the skin in large volumes Given via a butterfly needle to a large bit of skinthigh, tummy, chest wall Run via gravity- NOT THROUGH A PUMP Max is really 2 litres in 24 hours

30 Ellen Written up for 1 litre over 24 hours. The next day she has Respiratory secretions Ascites Large bruise Peripheral oedema

31 What would you do with her SC fluids?

32 Risks of SC fluid Fluid overload Respiratory secretions (maybe) Oedema Ascites Pleural effusion Bleeding Ideally have an idea of platelets and clotting function before hand, in practice try it and see Patient distress Fluid pooling

33 Evidence behind CAH at EOL Cochrane review 2014 Only 6 studies Basically not very good evidence either way Not harmful but also not really beneficial No evidence it prolongs life May cause harm SE Good, P. Richard, R. Syrmis, W. Jenkins-Marsh, S. Stephens, J. Medically assisted hydration for adult palliative care patients. 23 rd April Cochrane library

34 A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life. Davies et al. Palliative Medicine Vol 32(4) Withdrawal due to localised oedema and respiratory secretions. May delay the onset of hyperactive delirium May not affect the frequency of respiratory secretions (around 50% in both groups) May prolong the length of life

35 CAH, CAN at the end of life Not black and white Rarely appropriate to start CAN at end of life May be appropriate in last few months/weeks CAH at end of life is a risk vs benefit Reassess every 24 hours Have a clear aim Individual to each patient National guidance to assess hydration and nutrition DAILY so please document it!!!!!