Sara L. Bonnes, MD, MSdiscusses artificial Nutrition and Hydration in HPM. Learning Objectives: When are enteral feedings life prolonging in the setting of serious illness; Under what circumstances should I be recommending TPN to my palliative patients; Is TPN ever appropriate in hospice care
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Family Medicine & Primary Care Specialty
Internal Medicine Specialty
Psychiatry & Psychology Specialty
Hospice and Palliative Medicine Subspecialty

Mayo Clinic
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Past Notes
Thank you, Dr. Feeley, and thank you
for the opportunity to speak about
this topic that is near and dear
to my heart, and we find ourselves
in so many conversations about this.
So I'm hoping this is a helpful
session as I share some of
the things that I have learned over
the course of my career that
has helped guide my discussion with
patients as they are approaching
end of life or needing palliative
therapies.
I have no relevant disclosures
and we're going to divide
this into a couple of sections.
First, I'm going to give just some
background information that helps
frame how I think about this,
these nutrition questions.
But then we're also going to talk a
little more about enteral feeding,
the life prolonging or not life
prolonging nature of those.
When should we be considering TPN
for palliative patients
and should we consider TPN in
hospice care?
So for a clinical case, this
is not an uncommon scenario, we have
a young patient, this one a female
who was diagnosed with muteness
adenocarcinoma or pseudo myxoma
peritonitis.
She's admitted for management of a
malignant bowel obstruction.
She's previously had debulking
surgery and she's had hypercar
therapy.
Her obstruction is at multiple
locations in the bowel, including
Distel.
The surgeons say there's nothing
else that they can do.
Oncology says we've exhausted
chemotherapy options
up to this point in time.
Her functional status has been quite
good.
What would you recommend
when someone asks you what to do
for this patient's nutrition needs?
Would you do I.V. hydration,
consider enteral, consider
parenteral or really focus
on symptom management?
And so we certainly have a mix.
And these are challenging because
there are no great consensus
guidelines for many similar
patients. We have proceeded with
parenteral nutrition if we have a
slow or growing tumor with good
functional status.
And we'll talk a little bit more
about things to consider as we
proceed with nutrition
recommendations in situations like
this.
So as I was preparing for this and
just in general practice, there
are so many different societies
with different guidelines.
This is my attempt at recreating a
scatterplot, because depending on
where you look, you may find
different recommendations.
Much of the work on parenteral
and enter nutrition and end of life
is actually being done in Europe.
And so the European Society of
Parenteral and Enteral Nutrition has
some excellent recommendations.
The American Society of Parenteral
and Enteral Nutrition, or Aspen
is partnering with many other
groups and starting to have more
recommendations.
I came across very specific
recommendations from the Japanese
Society of Palliative Medicine that
I was not previously familiar with.
And the American Academy of Hospice
and Palliative Medicine also has
information.
So no wonder that there is
controversy because we have
many different recommendations,
depending on the group that you look
at.
As we frame this discussion
and even in the clinical case that
we have, it's always important
to determine what the patient's
nutrition goals are.
Are they hoping to have increased
energy or are they hoping to have
increased weight?
Have they been told that in order to
get additional chemotherapy, they
need to get some sort of nutrition?
Are they hoping to prolong life?
Is it a fear of starvation
or dehydration
or is it overall quality
of life?
And when they say they just want
to feel better, which I hear,
what symptoms are they really hoping
that the nutrition will help?
I was thinking about this in framing
this discussion.
Nutrition therapy is covered under
Medicare Part B, under
the Prosthetic Device Act.
And so officially, the government
here considers artificial
nutrition an artificial
gut.
And as we frame the discussions,
thinking about other organ
replacement systems, we don't
usually have a lighthearted
discussion about dialysis or
ventilation or other things.
And I realize risks and benefits
are different.
But I think it's also important
to consider that we truly are
bypassing a large organ system
when we're doing this.
And a discussion about this can be
very important and insightful
as well.
The coverage under the Prosthetic
Device Act also makes coverage
for artificial nutrition quite
complicated in many of
our patients who are covered by
Medicare and many insurances
in the U.S.
do follow the Medicare guidelines.
So looking to the European society
for guidelines, I think
they have some of the best and
they're usually in cancer patients,
but I think that they apply to many
other patients who are facing
terminal conditions or looking
at.
Conditions that are leading to end
of life and their goals
in these patients are preventing
and treating the undernutrition or
cachexia,
enhancing compliance with antitumor
or other treatments,
controlling some of the adverse
effects of antitumor therapies,
and overall improving the quality
of life for these patients.
As we talk about that, the European
guidelines do highlight that
every patient diagnosed with cancer
should have a nutrition screening
done really at the time of
diagnosis.
Many times this may be that at
that time they are doing fine and we
feel that they are not at any risk
of malnutrition or nutrition related
issues.
However, if that initial
conversation raises concerns
that they're not able to get
adequate nutrition or having
difficulty with GI function,
it's important to get
the assistance of a registered
dietitian or other nutrition
professional to do further
evaluations by
branch point. From there is can they
eat or can't they eat
if they can't eat?
We need to figure out where
nutrition falls in the scheme,
where we can utilize what they
have to continue to meet their
needs.
And if they can eat, then
the SGA is the subject
of global assessment, which is a
frequent nutrition screening tool
that's done all highlighted a little
bit more on the next slide.
Those who are at low risk or with
a score of a maybe
it's dietary counseling, monitoring
that intake.
But as treatment pursues
or as treatment continues, we
need to continue to reassess because
as disease progresses,
that risk for nutritional issues
can continue to change.
If we have some concerns,
calorie counts or dietary
counseling, looking at those
and if they truly are not able to
meet their nutrition needs early on
in the course of their disease,
considering oral supplementation
or supplementing with enteral foods.
So looking at the subjective global
assessment, there's a variety of
components and
one of the challenges is that some
of them are subjective.
So it truly takes a trained
professional to really utilize this
tool effectively, things
that any of us can do looking at
weight and weight trends, as Dr.
Verdian mentioned in his last talk,
that weight loss of greater than 10
percent in six months or
others are greater than five percent
in one month.
Those are quite concerning.
What are their dietary intake
patterns?
Are they just not eating and
drinking?
What GI symptoms do they have?
What else are you being asked to
assist and manage?
What's their functional capacity?
Dr. Verdian talked about frailty and
that correlates so well with some
of the things that we are looking at
with can they take care of
themselves? Are they able to walk?
What is their handgrip strength?
What are nutrition related
comorbidities, diabetes or
other issues?
And then nutrition focused physical
exam does look at muscle
wasting as well as fat loss.
The overall scoring for this is one
to seven, one to two, a severely
malnourished, three to five
moderate, and then six and seven
are very mild risk to of
being malnourished or being well
nourished.
I would also encourage all of us to
start this discussion early.
There is literature to suggest that
if I have to make the decision for
myself on what I
want, artificial nutrition or
artificial hydration at the end of
life, I would make a different
decision than if I had to make that
decision on behalf of a family
member.
And so looking at the University of
Munich a while ago,
almost 40 percent of patients
or they asked family members also
if you were choosing for yourself,
would you want artificial nutrition
or hydration?
And 40 percent said no.
However, if they were asked to
make that decision for a family
member or a loved one,
much fewer, many fewer of them
said no, that they would not
want, that they felt more compelled
to continue with the artificial
nutrition and hydration
for their loved ones as opposed to
what they wanted for themselves.
There was even more discordance when
they were looking at artificial
hydration alone.
When we look at the advanced
directive data that we have, it's
actually quite poor as well.
This is in our patient population,
the patients that I take care of,
those who are already on home,
parenteral nutrition, only 30
percent of them had an advanced
directive and less than half
of those dressed parenteral
nutrition, which they were already
on.
Looking at the same cohort in
Munich, only 18
percent of their cancer patients had
an advanced directive and
a quarter of those did not have a
decision on artificial nutrition.
So we are not we have significant
room for improvement at
having these discussions early and
documenting these decisions.
So when should I consider internal
nutrition or when should I advocate
for internal nutrition?
There's no clear answer.
Each patient is different.
Each situation is different.
What are key things to consider
as you're having this discussion?
What is the indication?
Can they swallow?
Does the gut work?
I love to have patients eat if
they can't eat.
That's not always an option.
And sometimes they simply can't eat
enough.
But that does impact my choice of
how I help meet their nutritional
needs.
What are their goals again?
What are they hoping to get from
this artificial nutrition?
How long do I think they need it?
What is their life expectancy?
And will get in a while to
a little more information on life
expectancy data.
What's their performance status?
Are they able to
tighten the connections and open
the cans and do all of the cars
that are necessary, or do they have
family who can assist with these
tasks?
Psychosocial evaluation is also
important, these patients
do have a higher risk of getting
depressed or having other issues
when we have all of these
significant changes going on in
their lives.
It's also important to consider are
they safe at home?
We have patients who unfortunately
don't understand the risks of tubes
or a tube gets dislodged and
they don't know how to appropriately
care for it.
What support do they have?
And do we think that they will be
able to complete these tasks
safely at home?
As I looked through the literature
to see the evidence on a life
prolonging with internal nutrition,
these are some of the key conditions
that came up.
I think we're familiar many times
with the stroke patients.
If they're having dysphasia, usually
we start with a nasogastric tube in
the short term and hope
that dysphasia improves.
If it does not improve,
then a percutaneous tube can
be beneficial.
We generally don't need to place a
post pyloric tube in these patients.
However, it can be considered
if the patient has significant
enough deficits, that they're going
to be mostly supine.
Malignancy is a common
situation where we are asked about
internal nutrition, and
it really does depend on the
location of the malignancy and the
anatomy, sometimes with even
a proximal obstruction, we're
able to place a tube distal to that
and continue to use the gut.
Life expectancy is also important
in this.
If life expectancy is less than a
month, it's generally not
recommended.
But a venting tube could be used
if needed for comfort.
For neurologic disorders, I
can't emphasize enough the
importance of that patient
discussion and knowing to some
extent the trajectory of their
disease in our patients
with ALS, we do have
those discussions early
and nutritional or enteral
nutrition may or may not have a
survival benefit.
I anticipate that as time goes on,
that question will be answered with
a little more clarity.
I was surprised a little bit with
the multiple sclerosis data.
But in patients with multiple
sclerosis, where it primarily
impacted swallowing,
it was associated with longer
survival.
Again, these patients did
not always have many other
deficits, but in those with
dysphagia, it could be helpful.
I'll be honest, I have not cared for
a patient with prion disease in many
years, but the literature
suggests that it is associated
with longer survival.
Advanced dementia is a question that
comes up quite frequently, and it
is important to remember that
internal nutrition, once patients
have really stopped eating, is
not associated with a survival
benefit for those
of us who are internists, this
is an American Board of Internal
Medicine Choosing Wisely initiative
to really make sure that we're
having important discussions with
these patients and being honest
about the disease
course in progression and
lack of benefit of enteral
feeding,
persistent vegetative state.
Again, I don't know that the data is
the best because it's very difficult
to truly get survival data
in patients where there is concern
that withholding nutrition or
withholding a therapy would lead to
adverse outcomes.
The data that we do have has
not demonstrated a survival benefit,
but I think that that remains
probably a more controversial area.
Regardless of the condition
for which this is being recommended,
what is going into the tube?
I am surprised at what people try
to put through some of these enteric
tubes.
Many patients across the U.S.
are going away from utilizing
the Canda feeds, and
sometimes family members are
blending up the table food and using
that through the tube, which can be
done safely and adequately.
But the family needs to know what
they're doing.
Many medications are able to be
safely administered through the
tube, but not all of them.
And like consent for any
other procedure and enteric tube
does require a procedure.
We've had patients with significant
complications of aspiration or
perforation.
Again, patients who are already
malnourished don't necessarily have
the best outcomes after a procedure.
There can be bleeding at the site,
infections at the site, poor
healing.
And I always encourage a trial of a
nasal feed prior to placing
a percutaneous tube, because
if they don't tolerate tube feeds,
then I want to avoid a procedure
that just puts them at increased
risk without a significant benefit.
It's also important to consider
where they're at and what their
schedule is like, as you know, in
the hospital.
We are very guilty of stopping and
starting tube feeds given upcoming
procedures.
For patients with recurrent
aspiration, it's important to have
this discussion because there are
many risk factors that contribute to
this enteric feeding is
actually associated with higher
aspiration. Rates in
oropharyngeal secretions are
frequently the culprit.
We have to remember to have good
oral hygiene, use
head of bad precautions with better
elevation.
And the data indicates that post
pyloric feeds may not be any
better than gastric feeds for
aspiration risk.
So truly use some of these
with caution, particularly
if your patient is supine and has
a gastric tube.
We strongly discourage use of
pump feeds because we can
expand that gastric volume and
then increase the reflux and risk
of aspiration.
Still, if you have patients
with recurrent aspiration, it
requires thoughtful discussion
because enteric feeding may not
be the answer and may not
help decrease their aspiration risk.
When should I be thinking about PN
for these patients,
the European guidelines, again, are
for incurable malignancy, but I
think are relevant to many areas.
They recommend considering
artificial nutrition if
death is not imminent
and it's expected that artificial
nutrition can stabilize or
improve the performance status of
quality of life
andrle nutrition is recommended to
minimize weight loss before
that dying phase has started
and consider parenteral nutrition.
If enteral nutrition is insufficient
or really not feasible, given
anatomy or other complications,
expected survival is
longer than two to three months.
It's thought that PDN can stabilize
or improve performance status of
quality of life, and
the patient desires this mode of
nutrition support.
I think it's really important,
again, to have that discussion and
understand what patients are
interested in.
I have patients who have told me
they don't want machines running
their life and that is part
of their hesitation with nutrition
or patients who just
feel that this would detract from
the things that they want to do.
The key topics when discussing
TPN are similar to N,
what is that indication
again, TPN is considered
a prosthetic GUTTE and
so also insurance coverage
can be an issue here.
What are their goals?
Duration of need, life expectancy,
usually that two to three months and
I'll show you some data shortly.
What's their performance status and
their ability to administer the pin?
What about family support
and the psychosocial evaluation
as well?
Are they safe at home?
And particularly before we
were discharging patients with a
central line?
Do they have a history of drug or
alcohol abuse or do they have
a history of recent suicide
attempts?
We have, unfortunately had patients
who have misused central access
to complete tasks of self harm.
So it's important to consider before
you send them out of the hospital.
Unfortunately, insurance coverage
can certainly be an issue
without insurance coverage,
home parenteral nutrition usually
costs about one hundred and fifty to
two hundred thousand dollars a year
in the U.S.
and that's generally not financially
feasible for my patients.
What does it look like at home?
You can certainly see here on the
left, the I.B.
pole with the bags and the multiple
pumps at home, are patients
actually get a portable backpack
like that on the right, the pump
fits in it, the TPN fits in it,
and they can take it with them.
The key differences in the hospital
the nurse administers at
home, we train patient our family
members to administer.
So particularly in patients with
poor functional status or
who are heading towards a more
palliative phase.
We need to have someone who can
assist when they are no longer able
to provide that care for themselves
in the hospital.
It's generally a 24 hour infusion
at home. Our goal is a 12 hour
infusion, but we're not always
able to get that depending on the
patient's physiologic tolerance.
And it's much more portable in
a backpack at home.
Looking at the survival and quality
of life for patients treated
at the Cancer Treatment Center of
America 2009 to 2011,
they had cachexia and compromised
function.
Anticipated survival was greater
than 90 days, but only
15 were really analyzed at that
three month period.
Many, unfortunately,
who dropped out did so because
they passed away or because they
entered hospice.
Of the thirty nine patients who had
one month follow up, they did have
improved performance skills,
improved fatigue, nausea and
constipation.
And twenty two of those patients
made it to two months, 15
to three months, and they continued
with the improved performance
status, physical function and
fatigue.
Quality of life really didn't
improve, though, until they hit that
two to three month mark.
Median survival in those with
a Karnofsky performance scale of
less than 50 was four point six
months and those with
a Karnofsky greater than fifty
six point four months.
So overall, functional status had a
significant correlation with how
they ended up doing.
Looking more at quality of life in
patients with a malignant bowel
obstruction median of four
months of TPN, we
again had improved weight, albumin
and performance status.
But quality of life really improved
in those who survived greater than
three months and did not do
so much for those who survived less
than three months.
Again, functional status before
starting TPN correlated with
longer survival
in this Japanese paper,
their median survival and patients
receiving IV hydration versus
TPN was 20 days.
Those who were on TPN
had a survival of 31 days
as compared to the median of 20.
But it didn't reach statistical
significance.
They said it was relatively longer
survival and the changes
in global quality of life did not
differ between those two groups.
So I think it's it does indicate,
depending on what you're trying to
get and that life expectancy.
Are we really aiming for hydration
versus nutrition?
As we look at life expectancy, which
is a common question, patients want
the TPN to keep them alive longer.
Nine of these patients with end
stage malignancy survived
less than two months.
Parenteral nutrition did not
contribute to death to any cancer
patients. And this was an important
statement because
many years ago, the gastro
and the GI societies actually
felt that pain potentially caused
harm in patients with advanced
malignancy.
And the data really is not
supporting that at this time.
Karnofsky, again, higher
than 50, correlated with better
survival, less than 50.
They did have a three month median
survival, but the survival
ranged from days to months.
And I think that's an important
point, is that it's so
hard to predict that survival.
Those who are on TPN longer
did have more complications.
What are those complications?
We can have infection, thrombosis.
They may need a procedure.
TPN may not fix electrolyte
imbalances.
We have patients who do need weekly
lab drawer's in order to maintain
that.
And TPN at home is
mixed usually for a week at a time.
So we cannot easily correct
electrolyte issues.
Lines can migrate
and I am surprised at the number
of dogs or turtles or
other things that have dislodged
a line or bitten off an end.
So be careful with what else
is in the house with that line.
Also, a word of caution.
Midline IVs can be used for many
things.
We have had patients who want to
incorrectly connect their TPN
to their midline I.V.
and that is not safe.
The concentration of the pen
will cause significant vein issues,
so make sure patients understand the
access that they have.
In a similar case, this patient has
done well if she misses a dose,
she gets muscle cramps and
dehydrated.
Unfortunately, she's got
new malignancy.
She plans to enroll in hospice.
And the question is, what do you
recommend about the TPN
again?
There's no clear consensus
guidelines, but when should I
consider TPN and hospice?
We have patients with short bowel
syndrome who get diagnosed with
malignancy. They've been on TPN
20 or 30 years
and they do have significant
symptoms without pain.
So it depends on where we're at in
this discussion.
If we're already at end of life,
it's generally harder to stop pian
than to not initiate pian.
So make sure you have a discussion
about goals of care early on
so that you can be consistent.
Why was the artificial nutrition
started if it is
because of a chronic condition
unrelated to their hospice
diagnosis?
It may very well be reasonable to
continue.
Will symptoms get worse by
stopping the TPN or may
they get better?
Are there additional treatment
options? Again, not necessarily
something as they are thinking about
hospice that they should be
considering other treatments.
But important to clarify,
what is the anticipated life
expectancy and
when is it no longer consistent with
patient goals or is
it causing harm?
And the harms I pay most attention
to are infections, electrolyte
issues and volume overload.
So in summary, artificial
nutrition is important to discuss
early on in the disease course,
it's hard to come up with consensus
guidelines because every patient
and situation is so different,
it may improve survival and quality
of life.
But certainly patients need to be
aware of the risks as well.
And artificial nutrition may not
be able to treat what the patient or
the family is most concerned about.
And we need to be aware and upfront
and honest at the beginning.
Patient wishes and expectations
are important.
It may not remain consistent with
goals of care.
And one of the common questions
is, is it going to feed my cancer?
And the answer is we don't
have data to support that.
Thank you very much for spending
this time with me.
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