Assessment and monitoring of nutritional status in patients with advanced cancer: part 1

A care ethics approach to a reduced ability to eat

Patients with advanced cancer often experience a reduced ability to eat, which may result in tensions between patients and family members. Often with advanced cancer diagnoses, patients' appetites decline markedly, while family members focus on nutritional intake with the hope that this will postpone death. This hope might cause tensions between the patient and family; the family may expect healthcare professionals to encourage the patient to eat more, whereas the patient needs to be supported in their reduced ability to eat. When these tensions arise, healthcare professionals can experience challenges in providing good palliative care. To address these challenges in the provision of palliative care, healthcare professionals may adopt a care ethics approach. Similar to palliative care's focus on patient and family members' relationships, a care ethics approach emphasizes interdependency and social relationships. Using Joan Tronto's care ethics approach, we conducted a normative analysis of what caring for patients with reduced ability to eat and their family members should look like. Tronto's approach includes five phases of care: caring about, taking care of, care giving, care-receiving, and caring with. Based on our analysis and empirical studies on patients with advanced cancer and family members, concerns with their lack of appetite, we assert that healthcare professionals must be mindful of the potential of tensions related to appetite and be adept in dealing with these tensions. We urge that education is needed for healthcare professionals regarding the psychosocial impact of reduced ability to eat on both patients and family members and interprofessional collaboration is of the essence.

Understanding and managing cancer-related weight loss and anorexia: insights from a systematic review of qualitative research

The aim of this study was to summarize the existing qualitative literature in order to develop the evidence base for understanding and managing weight loss and anorexia, in order to make recommendations for clinical practice. A systematic search was performed to retrieve English language studies using electronic search and manual checks of selected reference lists. Keywords included qualitative, cancer cachexia, weight loss, anorexia, appetite, malnutrition, food, eating, and drinking. The selection and appraisal of papers were undertaken by two reviewers. Twenty-one qualitative articles were included in the review. There were three major findings emerging from the previous qualitative studies including 'the multidimensionality of weight loss and anorexia experience', 'patients and caregivers' responses to coping with weight loss and anorexia', and 'clinical assessment and management of weight loss and anorexia'. The literature review revealed the multidimensional nature of cachexia and weight loss experience by patients and caregivers, which was not recognized and adequately managed by healthcare professionals. Future research in this area would be helpful in enabling a deeper understanding of the complexity of cachexia and weight loss experience in order to move forward to develop an optimal model of supportive care for patients and caregivers.

Psychosocial impact of cancer cachexia

BACKGROUND

Cancer cachexia has impact on patients and their family members. Patients experience loss of weight often accompanied by anorexia and other debilitating symptoms that have clinical impact and impact everyday life. The importance of understanding this impact lies in (1) the alleviation of cachexia-related suffering and (2) its implications for treating cachexia.

REVIEW

Two decades of exploratory investigation of the manifestations, meaning and management of cancer cachexia reveal emotional and social impacts for both patients and their carers. Patients can describe change in appearance and loss of physical strength often accompanied by change in eating habits (amount, type and pattern of food intake). The psychosocial effects can include loss of independence, sense of failure, sense of helplessness, conflict with family members over food, social isolation and thoughts of death. They are effects that can distress. Conversely, weight loss, especially early in its course and for those who are obese, can be perceived as beneficial, which inhibits self-management of diet and physical activity.

CONCLUSION

Models of the psychosocial effects of cancer cachexia have been developed, leading to, as yet unproven, propositions of how negative patient and family impacts can be addressed. This literature overlooks the potential importance of psychosocial intervention to emerging multimodal treatments for the multicausal syndrome. Psychosocial intervention in cachexia should be tested for potential to help people affected by cancer cachexia feel better but also for potential to make people better by aiding uptake and compliance with multimodal therapy.

Cancer cachexia care: the contribution of qualitative research to evidence-based practice

BACKGROUND

Despite its prevalence and prognostic impact, primary cachexia is not well understood. Its potential to cause considerable psychological stress indicates the need for qualitative research to help understand the perspectives of those affected.

OBJECTIVE

The aims of this study were to describe the perspectives of patients with primary cachexia, of their relatives, and of the healthcare professionals involved in their care and to demonstrate how this evidence can be applied in practice at 4 different levels of application ranging from empathy to coaching.

METHODS

A review of the qualitative literature and empirical qualitative investigation was used to understand the experiences of patients and relatives and the perspectives of professionals.

RESULTS

The main worries expressed by patients and relatives concerned appetite loss, changing appearance, prognosis, and social interaction. We also describe their coping responses and their views of professionals' responses. The main concerns of professionals related to poor communication, lack of clinical guidance, and lack of professional education.

CONCLUSIONS

Understanding patients', families', and professionals' perspectives, and mapping that understanding onto what we know about the trajectory and prognosis of the condition, provides the evidence base for good practice. Qualitative research has a central role to play in providing the knowledge base for the nursing care of patients with cachexia.

IMPLICATIONS FOR PRACTICE

The evidence provided can improve nurses' insight and assist them in assessment of status, the provision of guidance, and coaching. There is a need for the development of a holistic, information-based integrated care pathway for those with cancer cachexia and their families.

Outcomes of a nurse-delivered psychosocial intervention for weight- and eating-related distress in family carers of patients with advanced cancer

BACKGROUND

International expert consensus is that psychosocial intervention is likely to help advanced cancer patients and their family carers affected by weight loss and poor appetite.

PURPOSE

To investigate the potential for a psychosocial intervention, the Macmillan Approach to Weight and Eating (MAWE), to mitigate weight- and eating-related distress in carers of patients with advanced cancer.

METHOD

A controlled before and after study was conducted with carers of advanced cancer patients living in the community in the South of England in 2006-7. It used mixed methods to compare carers exposed to MAWE (n=12) with a control group (n=14).

RESULTS

Weight- and eating-related distress improved in carers exposed to MAWE. Qualitative analysis found that MAWE may help carers by providing information, reassurance, and support for self-management.

CONCLUSION

This preliminary study of MAWE suggests that it provides benefits as a supportive intervention. Further testing is warranted using a more robust experimental design.

Refractory cachexia and truth-telling about terminal prognosis: a qualitative study

The purpose of this paper is to examine the consequences that medical practitioners' decisions about whether or not to be candid about terminal prognosis have for those suffering from refractory cachexia and their families. It presents the findings of a qualitative study that used focus groups and semi-structured interviews of a volunteer sample of doctors, nurses and dieticians in a cancer centre of a large teaching hospital in Northern Ireland. Respondents reported that some physicians tended to avoid discussing terminal prognosis in a direct manner with their patients. Nurses and dieticians tended to be reluctant to engage in conversations about weight loss with patients with cachexia. One of the reasons they reported for their lack of acknowledgement of weight loss concerned the close association between refractory cachexia and terminal prognosis. Because they viewed the telling of bad news as an exclusive prerogative of medical practitioners, they did not feel in a position to discuss cachexia because they were concerned that this had the potential to raise end-of-life issues that lay outside the boundaries of their professional role. This meant patients and their families were provided with little information about how to cope with the distressing consequences of cachexia.

A qualitative analysis of the nutritional requirements of palliative care patients

BACKGROUND

The National Health Servive (NHS) Quality Improvement Scotland developed nutritional Clinical Standards to address the problem of malnutrition in hospitals. NHS palliative care units are obliged to incorporate these standards into nutritional aspects of care. The nutritional needs of this patient population are under-researched. The present study aimed to explore patients' views of nutrition, to begin to understand their concerns and to determine whether such standards meet the needs of patients in the palliative care setting.

METHODS

A qualitative study was conducted in 2009 in an NHS Palliative Care Unit. Six inpatients were involved in one-to-one interviews, which were audiotaped and transcribed verbatim. The transcripts were subject to qualitative data analysis in accordance with a previous framework.

RESULTS

A recurring theme that emerged was that of change and uncertainty. Four main areas subject to change were: disease state, symptoms, oral dietary intake and weight. Each change could exert control over, or be controlled by, the patient. When patients were eventually unable to exert control, they accepted the change, either willingly or enforced, thereby unintentionally setting their own targets.

CONCLUSIONS

The present study enables a deeper understanding of the concerns that palliative care patients have regarding their oral dietary intake and weight. Their 'malnutrition' not only refers to physical malnutrition alone, but also incorporates psychological and social 'malnutrition'. When applying standards or protocols regarding nutritional care, these wider issues must be taken into account to meet patients' nutritional needs.

The emotional aspects of cancer anorexia

PURPOSE OF REVIEW

To discuss the psychosocial support of people affected by cancer anorexia, drawing on recent publications.

RECENT FINDINGS

Recent studies describe the problem of distress in response to cancer anorexia. There are propositions of appropriate support and calls for the development of psychosocial interventions to relieve cachexia-related distress. Preliminary work is now testing these ideas.

SUMMARY

Psychosocial support for cancer anorexia is a new and promising field of study. The prevention or alleviation of the anorexia of cachexia would relieve much eating-related suffering experienced by patients and their families. However, whilst the scientific community works to achieve this goal there is another task to be addressed: to help people with cancer anorexia to adapt and live with the symptom. Despite accounts over many years of the distress caused by poor appetite, little attention has been paid to the potential for psychosocial support to aid self-management of the symptom. Emergent thinking is that psychosocial support for cancer anorexia can have benefit for both patients and their family members.

Attitudes towards weight and weight assessment in oncology patients: survey of hospice staff and patients with advanced cancer

The objective of this study was to compare attitudes of hospice staff towards weight loss and weight assessment in the hospice setting with those of patients with advanced malignancy in the hospital outpatient setting. Two paper-based questionnaires (one for staff and one for patients) were designed. The staff survey was circulated to all hospices in the UK and Ireland, and the patient questionnaire was given to patients attending three oncological care clinics in Belfast, Northern Ireland; Wolverhampton, England; and Auckland, New Zealand. The staff survey was posted to the medical director of each of the 215 hospices in the UK and Ireland. A total of 129 oncology outpatients with a confirmed diagnosis of malignancy and no longer receiving curative oncological interventions took part in the questionnaire. The main outcome measure was descriptive information about hospice weighing practices and attitudes of hospice staff towards weighing patients, and descriptive information was collected about patient attitudes to weighing and weight loss. We found that weighing practices vary across hospices in UK and Ireland. Patients attending the majority of hospices, 96/146 (66%), are rarely weighed. A little over half of hospice staff, 81/146 (56%) considered that weighing could cause patients to be upset. However, 124/129 (96%) of patients with advanced cancer reported that they had never found the experience of being weighed in a healthcare facility upsetting. Some 95/129 (74%) of patients weighed themselves at home and 89% would want to know if their weight was changing. While there is reluctance on the part of many hospice staff to weigh patients, most patients with advanced malignancy in the hospital setting do not report weight measurement to be upsetting.

Correspondence

Dewey and Dean (2007) report the findings of semi-structured interviews with 14 hospital and community nurses involved in the delivery of palliative care. They found that the nurses did not routinely assess nutritional status, but waited for the patient/carer to raise concern about weight loss before conducting informal assessment and considering nutritional management. The findings are important given the National Institute for Health and Clinical Excellence (NICE) guidance (2006) that recommends that all patients are screened for malnutrition on entry to primary or secondary care.