Nutritional Issues in End of Life Flashcards
refers to tube feeding and/or intravenous fluids as a medical therapy
artificial nutrition and hydration (ANH)
condition expected to lead to death
terminal
the process of terminating life-sustaining treatments
withdrawal of care
describes patients or family’s wishes regarding resuscitation
code status
all efforts to resuscitate patient should be made, including CPR and mechanical ventilation
full code
customizable, may desire CPR, but no mechanical ventilation or vise versa
limited code
allows death to occur without intercession
DNR/DNI
do not resuscitate/do not intibate
appoints individuals to make health-related decisions hen an individual is incapacitated
health care proxy
- health care power of attorny
defines patients wishes for medical treatment in case of coma, terminal illness, or persistent vegetative state
living will
ne document defining wishes regarding specific treatments and medical care
physicians orders for life sustaining treatment (POLST)
Any nutrition and/or hydration support of an invasive nature requiring placement of a tube into the alimentary tract or parenterally via intravenous or subcutaneous means
artificial nutrition and hydration (ANH)
Is withholding or withdrawing ANH the same as denying food and drink?
no
can patients refuse hydration
yes
provides physical symptom management, emotional support, and spiritual comfort when no curative therapy is available or after making the decision to no longer continue curative or life-prolonging therapies
palliative care
integrates palliative care into focus on relieving the substantial symptom burden patients face at the end of life, as well as advanced care planning needs, existential concerns, and family and social stressors
hospice care
palliative care is_______ management and designed to improve quality of life
- utilized for serious and chronic diseases
- can be used concurrently with curative treatment
some examples?
symptom
anxiety, depression, loss of appetite, pain, nausea, diarrhea, shortness of breath, difficulty sleeping
Central ethical question: is it painful not to have access to food & water when dying?
* Hospice professionals have long observed that terminally ill patients experience ______ hunger & thirst and stop eating and drinking
* The analgesic theory proposes that starvation increases production of ______ which may have an ______ effect
no
decreased
ketones
anesthetic (calming)
Artificial hydration can cause discomfort from increased _______ and _________ from fluid retention
* Thought that most discomfort is due to ______=> alleviate with ice chips, sips of favorite beverages, and good mouth care
urine output
respiratory distress
dry mouth
ANH in ______ includes Alzheimers, Parkinson’s, alcohol-related, and other etiologies.
- progressive cognitive and physical decline
- dysphagia and inability to self-feed are normal sequelae
- discuss nutrition implications early in disease development
hand feeding?
advanced dementia
hand feeding can help these patients
Placement of _______ is typically the method of choice for long-term tube feeding
* No proven long-term benefits for individuals with advanced dementia
* Does not reduce _______
* Increases morbidity & mortality
* Often result in=> increased discomfort, use of physical or chemical restraints, increased risk of pressure ulcers, and compromised human dignity
PEG tubes
aspiration
Why are PEG tubes often placed?
* Lack of knowledge of risks vs. benefits
* Belief by health care professionals that they will reduce morbidity & mortality
* Demands of ____________
* Fear of __________
family members
lawsuits
Oral feeding should be advocated whenever possible
* Patient’s ____________ of food should be primary consideration. Family & staff should be encouraged to assist in feeding the patient
* Diet restrictions should be individualized or liberalized
* Suboptimal oral feedings may be more appropriate than tube or parenteral feedings
emotional enjoyment
absence of responsiveness & awareness due to overwhelming dysfunction of the cerebral hemispheres, with sufficient sparing of the brain stem to preserve autonomic & motor reflexes
vegetative state
vegetative state caused by _________
Patients may have reflexes, including eye movements, yawning, and involuntary movements, but show no awareness of __________
brain injuries
self or environment
Patients who remains in a vegetative state for > 1 month=> __________
Persistent Vegetative State (PVS)
If remain unconscious for > 3 months (if non-trauma cause ) or
> 1 year if trauma is the cause are deemed in a __________
permanent vegetative state
If remain unconscious for > ____ months (if non-trauma cause ) or > ___ year if trauma is the cause are deemed in a permanent vegetative state
3
1
One of the most difficult decisions facing health care providers & families is whether to place or remove a PEG tube in a PVS patient
* Current findings/conclusions
* Consciousness appears to be a prerequisite for suffering
* Neuroscience supports that PVS patients _________
do not suffer
Terri Schiavo Case
* Patient in PVS for ___ years
* No advanced directive was left, principle of substituted judgment was applied
15
Many believe it is more acceptable to _____ a treatment than to _____ it
* No ethical or legal distinction between them
* However, the decision to _____ ANH can be more psychologically distressing to family and practitioners
* A decisionally capable person may refuse any form of life-saving treatments
withhold
withdraw
withdraw
Be a patient advocate - RDN may be able to best express the needs and wants of the patient and family since the RDN is the main conversation partner for issues related to nutrition
- Provide ____ that reduce the side effects of medicine and treatment
- Encourage families to suggest the patients favorite meals, when appropriate, and participate in ____ feeding
meals
hand
for pediatric patients, ____ generally responsible for decision-making
- withdrawal/withholding of ANH to infants is particularly difficult because they lack autonomy to ______ in any way
___ exist to prevent abuse-related withdrawal/withholding of ANH
parents
feed themselves
laws
Collaborate with health care team to make ___________ recommendations
* Facilitate policy-making and become involved in the institution’s ethics committee
* Enhance health literacy about ANH – benefits & burdens
* Consider ________ diversity concerning life-sustaining treatments
nutrition & hydration
cultural and religious
the rules and standards governing the conduct or members of a profession
ethics
- the study of the controversial ethical issues emerging from new situations and possibilities brought about by advances in medical technology
- encompasses theoretical, clinical, regulatory and policy/cultural domains
- what can be done (the technology) vs. what should be done (ethics) vs. what must be done (law)
bioethics
A patient with intact decisional capacity may refuse ANH even if medically recommended.
autonomy
A nutrition support professional may recommend a temporary PEG tube for patients undergoing chemotherapy and radiation of gastric cancer.
beneficience
A nutrition support professional may recommend against ANH in a patient if it decreases quality of life and outcomes.
Non-maleficence
Lack of access to appropriate hospice and palliative care may lead to overuse of ANH in disadvantaged cohorts.
justice
Communication & Compassion
* Some families will request that “everything be done”
* Effective ___________ can help prevent ethical dilemmas
* Explain risks and burdens of ANH
* Clinicians are not obligated to provide futile treatment
* Judgment of what is “futile” considers goals of care, proposed treatment, the outcome
communication
