Artificial nutrition and hydration in terminal cancer patients: the real and the ideal

INTRODUCTION

To better understand current practice relating to artificial nutrition/hydration in terminal cancer patients, we enrolled terminal cancer patients who were admitted at Seoul National University Boramae Hospital for supportive care only and who died with a duration of hospital stay to death of more than 1 week between 2003 and 2004. We detailed oral intake and intravenous nutrition/hydration status on admission, 1 week after admission, and 2 days before death. Administered calories and changes in these according to time and "DNR" (do-not-resuscitate) status were noted.

RESULTS

Of the total 165 patients, oral intake was possible in 84 patients (50.9%) on admission, in 79 patients (47.8%) on 1 week after admission, and in 29 patients (17.5%) 2 days before death (p < 0.01). Intravenous nutrition/hydration was administered to 133 patients (80.6%) on admission, to 125 patients (75.7%) at 1 week, and to 137 patients (83.0%) 2 days before death (p = 0.7). The calories administered to the patient by oral intake were 393 kcal on admission, 353 kcal 1 week after admission, and 89 kcal 2 days before death. In addition, the calories delivered by intravenous fluid were 369, 386 and 465 kcal, respectively. Near to death, calories by oral intake continuously reduced (p < 0.01) and intravenous calories continuously increased (p = 0.04), but total administered calories reduced (p = 0.03). Intravenous nutrition/hydration stopped after the attainment of the advance directive of DNR in 9% of patients.

CONCLUSION

This study showed the high prevalence of artificial nutrition/hydration, especially intravenous infusion, in Korean terminal cancer patients compared with situation in other countries. More studies are needed to verify the efficacy of artificial nutrition/hydration in terminal cancer patients.

Adult home parenteral nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

AIM

To evaluate the current use of Home Parenteral Nutrition (HPN) in a Southern European region.

SUBJECTS AND METHODS

A total of 159 (86 m, 73 f) HPN patients, mean age 60.1 +/- 14.2 years, BMI 18.8 +/- 3.3kg/m2, consecutively referred to the Artificial Nutrition outpatient Unit of the Federico II University Hospital in Naples (Italy), from January 2000 to December 2002 and treated for at least 4 weeks. Retrospective evaluation of baseline disease, indications and duration of HPN treatment, type of venous access, complications.

RESULTS

In all, 140 (88%) were cancer and 19 (12%) noncancer patients. Main indications were carcinosis in 68 for total, and hypophagia/dysphagia in 62 patients for partial/integrative (to oral-enteral nutrition) HPN; mean duration of HPN was 81.45 +/- 110.86 days of treatment and infection rate 2.89% in the whole population and 2.66% in the 36 patients treated for more than 3 months. No other major complications have been observed.

CONCLUSION

HPN is confirmed to be a safe and effective treatment when prescribed and administered by a trained team.

Parenteral Nutrition in Advanced Cancer: Indications and Clinical Practice Guidelines

Cachexia is a disturbing and disfiguring aspect of many advanced cancers. Parenteral nutrition (PN) is a controversial and expensive treatment for cancer cachexia. Guidelines for the use of PN for these patients have been suggested. These two case reports will highlight some of the issues around the etiology of cancer cachexia, the clinical dilemmas and the use of clinical practice guidelines.

Is there a role for TPN in terminally ill patients with bowel obstruction?

OBJECTIVE

There is controversy regarding the use of total parenteral nutrition (TPN) in individuals with metastatic malignancies. The objective of this study was to determine whether a subgroup of patients with intestinal obstruction would benefit from support with TPN.

METHODS

A retrospective review of patients considered for home TPN by a regionalized home TPN program was conducted

RESULTS

Over a 6-y period, nine patients with primary gastrointestinal malignancy and metastatic intestinal obstruction were identified. There was a variable survival rate of 27 to 433 d. Survival rate longer than 60 d was noted in six of nine patients. Most patients had no direct TPN-related complications, but one patient had significant morbidity related to venous thrombosis and line sepsis. There were no nutritional predictors of prolonged survival rate with TPN. TPN was continued until death in six of nine patients.

CONCLUSION

Patients with small bowel obstruction and metastatic malignancy may benefit from TPN as demonstrated by prolonged survival rate longer than 60 d. There are no clear predictors of who will benefit from TPN, and each case should be considered individually, with the potential risks and benefits discussed with the family and primary caregivers. Future studies should address the effect of TPN on quality of life of the patient and their caregivers.

Nutritional issues in palliative care

OBJECTIVES

To present current information on nutritional problems and management during the palliative care period.

DATA SOURCES

Research and review articles from three computerized databases, the table of contents of an on-line nursing journal, and pursuit of pertinent references in articles reviewed.

CONCLUSIONS

Controversies continue on the most appropriate management of intake in the palliative care period from both physical and ethical perspectives.

IMPLICATIONS FOR NURSING PRACTICE

Until the literature is conclusive on the amount and type of suffering incurred by patients who are ceasing intake, nurses will need to stay current with the research literature and approach each case individually in determining appropriate care.