The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
Education in Palliative and End-of-life Care - Oncology
The
ProjectEPEC-OTM
EEPPEECC
OO Module 11Module 11
Withdrawing Nutrition, Hydration
EPEC - Oncology Education in Palliative and End-of-life Care - Oncology
Overall message
Withholding or withdrawing a Withholding or withdrawing a therapy, such as artificial therapy, such as artificial
nutrition or hydration, is ethical nutrition or hydration, is ethical and legal in some and legal in some
circumstancescircumstances
Objectives Withholding or withdrawing therapyWithholding or withdrawing therapy Evidence base for artificial nutrition Evidence base for artificial nutrition
and hydrationand hydration Approach to discussing artificial Approach to discussing artificial
nutrition and hydrationnutrition and hydration Features of artificial nutrition and Features of artificial nutrition and
hydration that favor use in spite of hydration that favor use in spite of the evidencethe evidence
Video
Role of the oncologist . . . Help the patient and family Help the patient and family
Elucidate their valuesElucidate their valuesUnderstand the factsUnderstand the factsDispel misconceptionsDispel misconceptions
Establish goals of careEstablish goals of care Facilitate decisions, reassess Facilitate decisions, reassess
regularlyregularly
. . . Role of the oncologist Discuss alternativesDiscuss alternatives
Including palliative and hospice careIncluding palliative and hospice care Document preferences, medical Document preferences, medical
ordersorders Involve, inform other team membersInvolve, inform other team members Assure comfort, non-abandonmentAssure comfort, non-abandonment
Life-sustaining treatments ResuscitationResuscitation Elective Elective
intubationintubation SurgerySurgery DialysisDialysis Blood Blood
transfusions, transfusions, blood productsblood products
Diagnostic testsDiagnostic tests Artificial Artificial
nutrition, nutrition, hydrationhydration
AntibioticsAntibiotics Other treatmentsOther treatments Future hospital, Future hospital,
ICU admissionsICU admissions
Enteral nutrition NG, PEG, J tubesNG, PEG, J tubes Use GI tractUse GI tract Temporary inability to eatTemporary inability to eat Neurological injuryNeurological injury UGI mechanical obstructionUGI mechanical obstruction
Shike M. Hematol Oncol Clin North Am, 1996.
Effect of enteral nutrition on survival Higher mortalityHigher mortality
50% dead at 12 months50% dead at 12 months60% dead at 18 months60% dead at 18 months
No reduction in aspirationNo reduction in aspiration No reduction in risk of pneumoniaNo reduction in risk of pneumonia No evidence of better symptom No evidence of better symptom
controlcontrolFinucane TE, Christmas C, Travis K. JAMA, 1999.
Parenteral nutrition Intravenous (central line)Intravenous (central line) No benefit in routine perioperative, No benefit in routine perioperative,
ICU settingsICU settings Benefit in prolonged GI tract toxicityBenefit in prolonged GI tract toxicity Benefit in absence of GI tract Benefit in absence of GI tract
function in otherwise healthy patient function in otherwise healthy patient (short gut)(short gut)
Mercandante S. Support Care Cancer, 1998.
Effect of parenteral nutrition on survival and response rates
Odds ratioOdds ratio
ControlControl 1.00 1.00
SurvivalSurvival 0.810.81p < 0.05p < 0.05
Tumor Tumor responseresponse 0.680.68
ACP Consensus Statement. Ann Int Med, 1989.
Evidence conclusion When cancer is the cause of the When cancer is the cause of the
anorexia and weight loss, anorexia and weight loss, prospective randomized studies have prospective randomized studies have failed to show benefit of artificial failed to show benefit of artificial nutritionnutrition
ACP Consensus Statement. Ann Int Med, 1989.
Parenteral hydration IntravenousIntravenous Subcutaneous (hypodermoclysis)Subcutaneous (hypodermoclysis)
Equally efficacious, less risk, less skill, Equally efficacious, less risk, less skill, less costless cost
Doesn’t relieve dry mouthDoesn’t relieve dry mouth
McCann RM, Hall WJ, Groth-Juncker A. JAMA, 1994.
Common concerns Legally required to ‘do everything’?Legally required to ‘do everything’? Is withdrawal, withholding Is withdrawal, withholding
euthanasia?euthanasia? Are you killing the patient when you Are you killing the patient when you
withhold or withdraw artificial withhold or withdraw artificial nutrition and hydration?nutrition and hydration?
7 steps to discuss nutrition & hydration . . .1.1. Be familiar with policies, statutesBe familiar with policies, statutes
Appropriate setting for the discussionAppropriate setting for the discussion
2.2. Ask the patient, family what they Ask the patient, family what they understandunderstand
3.3. Discuss general goals of careDiscuss general goals of care
. . . 7 steps to discuss nutrition & hydration4.4. Establish context for the discussionEstablish context for the discussion
Discuss specific treatment preferences: Discuss specific treatment preferences: will nutrition & hydration achieve goals?will nutrition & hydration achieve goals?
5.5. Respond to emotionsRespond to emotions
6.6. Establish and implement the planEstablish and implement the plan
7.7. Reassess and revise periodicallyReassess and revise periodically
Address misperceptions Cause of poor appetite, fatigueCause of poor appetite, fatigue Relief of dry mouthRelief of dry mouth Urine outputUrine output
Emotions Not ‘fighting’Not ‘fighting’ Not ‘doing something’Not ‘doing something’ ‘‘Starving to death’Starving to death’ ‘‘Dehydrating to death’Dehydrating to death’ Let nature take its courseLet nature take its course
McClement, et al. J Palliat Med, 2003.
Help family and staff Identify feelings, emotions, need ‘to Identify feelings, emotions, need ‘to
do something’do something’ Identify other ways to demonstrate Identify other ways to demonstrate
caringcaringTeach the skills they needTeach the skills they need
Normal dying Loss of appetiteLoss of appetite Decreased oral fluid intakeDecreased oral fluid intake Artificial food / fluids may make Artificial food / fluids may make
situation worsesituation worseBreathlessnessBreathlessnessEdemaEdemaAscitesAscitesNausea / vomitingNausea / vomiting
Ganzini L, et al. N Engl J Med, 2003.
Discussing hospice care Hospice care - present as a response Hospice care - present as a response
to need vs. something to do when to need vs. something to do when nothing left to donothing left to do
Elicit patient and family Elicit patient and family understanding of situationunderstanding of situation
10-15% of patients referred to 10-15% of patients referred to hospice care disenroll (graduate)hospice care disenroll (graduate)
EEPPEECC
OO
Summary
Withholding or withdrawing a Withholding or withdrawing a therapy, such as artificial therapy, such as artificial
nutrition or hydration, is ethical nutrition or hydration, is ethical and legal in some and legal in some
circumstancescircumstances
