Nutritional Considerations at the End of Life Flashcards
Discuss the risk of malnutrition in malignant disease.
- 20-70% prevalence depending on patient age, cancer type and cancer stage.
- ↑ in older vs. younger adults and advanced stages of disease.
- Can lead to changes in body composition and functional status, reduced response to treatment and reduced survival.
Describe the factors which contribute to the development of malnutrition in malignant disease.
- Increased risk of malnutrition in cancer secondary to:
- Impaired dietary intake
- Changes in metabolism
- Leads to development of cancer cachexia:
- “A multifactorial syndrome characterised by ongoing loss of skeletal muscle mass (with or without fat loss) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.”
What are the causes of impaired dietary intake?
- Physical symptoms
- Can impair food intake, nutrient absorption or increase nutrient losses.
- Psychological effects
- Diagnosis: anxiety and depression which can negatively impact on nutritional intake.
- Systemic effects
- Redution of appetite and development of anorexia.
- Treatment and side effects
- Can further impair nutritional intake and increase the risk of malnutrition.
What are the causes of changes in metabolism associated with cancer?
- Systemic inflammation syndrome (common in cancer) drives:
- Alterations in protein, fat and CHO metabolism
- Loss of fat and muscle mass
- Insulin resistance
- Impaired glucose tolerance
- Symptoms of fatigue, weight loss and impaired physical activity.
- Increases in resting energy expenditure may also be observed.
- Alterations in protein, fat and CHO metabolism
What are the consequences of malnutrition in malignant disease?
- Loss of weight
- Loss of muscle mass
- Reduced immune competence
- Psychosocial stress
- Lower QoL
- Greater mortality
What is the purpose of nutritional risk screening in malignant disease?
When and how should this be done?
- Aims to increase awareness and allow early recognition and treatment.
- Screen for nutritional risk:
- As soon as the diagnosis of cancer is made
- Repeat at regular intervals
- ESPEN, 2017 guidelines recommend the use of a validated screening tool and evaluation of:
- BMI
- Weight change
- Nutritional intake
What are the different types of nutritional support?
- Increasing the frequency and energy density of foods and beverages consumed.
- Food enrichment measures and use of high energy snacks.
- Specific dietary approaches for particular diagnoses.
- Remedial measured to alleviate disease and treatment side effects.
- All this +/- oral nutritional supplements.
Can increase energy intake, body weight and improve quality of life.
Describe the dietary implications which should be considered in a neutropaenic patient.
- Neutropaenia is a side effect of many anti-cancer treatments.
- Individuals undergoing high dose chemotherapy and stem cell transplants are at particularly high risk.
- Increases the risk of bacterial sepsis, pneumonia and fungal infections.
- Greater risk of infection from bacteria or fungus in food:
- Neutrophils that fight food poisoning bacteria are low.
- Gut lining which acts as a barrier between bacteria and the blood stream is damaged.
When is artificial nutrition support indicated in patients with malignant disease?
- May be indicated following some types of surgery or treatment or in some cases prior to treatment commencing.
- “If a decision is made to feed an individual, enteral nutrition is recommended if oral nutrition remains inadequate and parenteral nutrition if enteral nutrition is not sufficient or feasible.”
What are the advantages of enteral nutrition vs. parenteral nutrition?
- Maintenance of gut barrier function
- Less infectious complications
- Lower cost
What is immunonutrition?
- Immunonutrition = nutrition with anti-catabolic and inflammation supressing ingredients.
- Trend toward reduced infective complications and total postoperative complications.
- Includes arginine, glutamine, n-3 fatty acids and ribonucleic acid in various combinations and doses.
What are the nutritional implications of chemotherapy?
How should these be treated?
- ↓ appetite and dietary intake.
- These side effects occur in up to 79% of patients during treatment.
- Leads to deterioration in nutritional status.
- Dietetic counselling +/- oral nutritional supplements may improve nutritional intake, quality of life and stabilise weight in individuals undergoing chemotherapy.
Good symptom management is essential.
What is mucositis?
What are the dietary strategies in patients with mucositis?
- Mucositis is the painful inflammation and ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiotherapy treatment for cancer.
- Up to 80% experience severe mucositis.
- Can last 1-3 weeks.
- Consider nutritional support alongside medical management.
- Dietary strategies:
- Avoid very dry or rough textured foods.
- Avoid foods and drinks at extremes of temperature.
- Avoid very salty or highly spiced foods and tarte beverages.
What are the dietary strategies used in patients with nausea and vomiting?
- Will affect ~50% of patients at some point during illness.
- Can significantly impair nutritional intake.
- Can make every day life very difficult to cope with.
- Good medical management is essential.
What are the nutritional implications of targeted therapies?
- Targeted therapies act on specific molecular targets that are associated with the cancer.
- Targeted therapies are often cytostatic.
- Some of the side effects of thalidomide and bortezomib which can impact on nutritional intake and nutritional status include:
- Nausea and vomiting
- Fatigue
- Diarrhoea and constipation
What are the nutritional implications of radiotherapy?
- During radiotherapy an adequate nutritional intake should be ensured primarily by individualised nutritional counselling and/or nutritional supplements.
- All patients undergoing radiotherapy of the head and neck or gastrointestinal tract should receive nutritional assessment.
What are the nutritional implications of surgery?
What are the consequences of pre-operative malnutrition in cancer patients?
What are the physical activity considerations during cancer treatment?
What is the role of nutritional support in palliative and end-of-life care?
- To provide quality of life.
- Relief from symptoms, pain and stress of a serious illness.
- Appropriate at any age and any stage in a serious illness.
- Role of the dietician within the palliative care setting:
- To help identify and address any nutrition-related factors that impair physical and psychological wellbeing with the primary nutritional objective of maintaining or improving quality of life.
- Eating can help maintain a sense of normality.
- Difficulties with food and fluid can lead to:
- Social isolation
- Barriers within the family unit
- Impaired quaity of life
What are the principal objectives of nutritional management in palliative care?
What are the benefits, harms, risks and burdens of artificial nutrition support in palliative care?
- Potential to increase survival.
- Potential to increase quality of life.
- Artificial nutrition support in palliative care is a medical treatment.
- The provision, withdrawal or witholding of nutrition should be driven by ethical principles of:
- Respect for autonomy
- Beneficence
- Non-maleficence
- Justice
