NUTRITION AT END-OF-LIFE HANDOUTS OBJECTIVES. Hospice Education Network. Nutrition at End-of-Life, by C. Andrew Martin, MS, RN, CHPN

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1 NUTRITION AT END-OF-LIFE C. Andrew Martin, MS RN CHPN Hospice Education Network HANDOUTS Pause the presentation Click on the link for the PowerPoint handouts and any supplemental materials Download the handouts (PDF files) Print the handouts 2 The learner will: OBJECTIVES Identify nutritional care givers as both family and professionals, located in various care settings List some components of a nutritional assessment List nutritional support activities Identify cultural, personal and ethical issues concerning nutrition at end-of-life 3

2 DEFINITIONS Nutrition: the act of nourishing or of being nourished Hydration: the act of giving liquids to the body They are basic care giving activities They are opportunities for social interaction between patient and care giver, whether family or professional 4 Life cycle events Birthdays Weddings Anniversaries Funerals Caring activities Newborns Illness Dying FOOD IS LOVE 5 NUTRITIONAL SUPPORT AT END-OF-LIFE Nutrition may be beneficial early in the disease process Six month prognosis Educate care givers in understanding nutritional needs and limitations in terminal situations Develop an individualized approach to each patient 6

3 CARING PARTNERS Hospice Family Inpatient facility staff Collaboration Conflict resolution 7 HOSPICE IN THE INPATIENT FACILITY Documentation must meet the regulations for both agencies Documentation must indicate coordination of the plan of care Goals of both agencies must agree Hospice manages the plan of care 8 CARE PLANNING Normal for a hospice patient to have: Decreased appetite Decreased fluid intake Nutrition is part of the care plan Trajectory of the disease Patient/family wishes 9

4 CARE GIVING ASSESSMENT Care giving settings may be: Home Inpatient Facility Care givers may be: Family, friends, or healthcare professionals 10 NUTRITIONAL ASSESSMENT Diet history Eating habits Food preferences Food aversions Weight loss history Certification and re-certification periods Physical exam oral 11 PHARMACOLOGICAL ASSESSMENT Steroids Increase appetite Megastrol acetate Increase appetite 12

5 SOME CARE GIVER BELIEFS Undernourished patients may experience hunger Dehydration may result in: Thirst Dry mouth Headache Delirium Nausea Vomiting Abdominal cramps 13 NUTRITION FACTS Decreased appetite and thirst is a natural process in dying Not providing food and water at end-of-life may be difficult for care givers Nutrition and hydration may cause patient discomfort Food aspiration Fluid overload When nutrition is ceased, metabolic changes may result in elevated level of ketones May produce mild euphoria Decreased pain sensation 14 NURSING INTERVENTIONS Symptom management Constipation Pain Nausea Negative affect on appetite Provide meticulous oral care Promote an atmosphere of unhurried meals 15

6 ADJUNCT DISCIPLINES ASSESSMENTS Speech Therapist Identify risk factors for complications of oral and tube feeding Nutritionist Evaluate quality of intake Supplemental sources of protein and calories Recommend specific formulas based upon body functions Heart, Liver, Kidneys 16 #1 NUTRITIONAL RISK FACTOR Pressure ulcers View as one part of the overall palliative care treatment plan Determine the degree of aggressive treatment 17 PRESSURE ULCERS Negative outcome, whether in the home or inpatient setting Low protein intake Low serum albumin levels Preventative goal of care may be to provide: calories per kilogram of weight per day g of protein per kilogram of weight per day Nutritional supplementation may not be appropriate in all end-of-life cases 18

7 CATABOLIC STATE In the dying process, metabolism begins to shut down Body tissues begin to break down, regardless of nutritional intake Decreased healing Increased infections Overall downward spiral Nutrients do not necessarily stop this catabolic process Feeding tube Total parenteral nutrition (TPN) intravenous 19 SUPPLEMENTAL TEACHING MATERIALS Hospice and Palliative Nurses Association Patient/Family Teaching Sheets Food and Fluid at End of Life 20 WHAT TO REPORT TO THE IDG Tell the Hospice/Palliative Care Team if the patient: Is unable to eat or drink Has trouble swallowing Has a dry mouth or tongue Loses more than five pounds in a week Has less urine Becomes confused or drowsy HPNA Patient/Family Teaching Sheet: Food and Fluid at End of Life. 21

8 THINGS YOU CAN DO Encourage favorite foods and drinks Offer drinks or sips often at least every two hours Clean the mouth often a pleasant tasting mouth may make food taste better 22 THINGS YOU CAN DO Help other family members and friends understand why eating and drinking may cause the patient to be uncomfortable Support the patient s decision not to eat or drink Encourage the patient to rest before and after a meal 23 THINGS YOU CAN DO If dentures do not fit well, consult a dentist Make mealtime a quiet and pleasant time candles, flowers, soft music and good conversation all help Offer small meals and use smaller dishes 24

9 THINGS YOU CAN DO If nausea is a problem, serve small portions of salty (not sweet), dry foods and clear liquids Find other ways besides food and drink to show the patient you care. For example, offer the patient a massage or look through a picture album together. HPNA Patient/Family Teaching Sheet: Food and Fluid at End of Life CULTURAL/PERSONAL ISSUES Honoring food choices Vegetarian, vegan Kosher 26 ETHICAL ISSUES Hospice philosophy is to promote patient comfort and quality of life, minimize suffering and discomfort Review Advanced Directives Identify surrogate decision makers 27

10 ARTIFICIAL NUTRITION AND HYDRATION (ANH) Consider benefits and burdens of treatment Usual therapeutic goals of ANH Prolong life Prevent aspiration pneumonia Maintain independence Decrease suffering at end-of-life 28 TUBE FEEDINGS Studies indicate that tube feedings do not appear to prolong life in most patients with lifelimiting, progressive disease Potential complications from tube placement may increase mortality May increase the risk for aspiration and its complications 29 AHN BURDENS Potential discomfort Repeated venipunctures Iatrogenic infections Inpatient setting acquired Increased edema Increased respiratory tract secretions Fluid overload Skin excoriation around the feeding tube Potential of physical restraints 30

11 CONCLUSION Importance of care giver support, whether family or professional, regarding nutritional issues When feeding activities are no longer possible or reasonable: Families and other care givers need education and support to provide both comfort and social interaction 31 REFERENCES / HANDOUTS Hospice and Palliative Nurses Association. Patient/Family Teaching Sheet: Food and Fluid Issues at End of Life. Hospice and Palliative Nurses Association. HPNA Position Statement: Artificial Nutrition and Hydration in End-of-Life Care THANK YOU! C. Andrew Martin, MS RN CHPN camartin@hospiceonline.com 33