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

Nutrition provided during the final weeks to patients with non-gastrointestinal solid malignancies

BACKGROUND & AIMS

Data regarding the delivery of nutrition and nutritional infusions to patients with terminal cancer remain limited; therefore, this real-world analysis investigated differences in nutrition delivery and infusion statuses for patients with terminal-stage cancers.

METHODS

Patients who had died following hospitalization for more than seven days due to neoplasms between April 2014 and December 2018 were identified using the medical claims database of Japan. Data regarding oral diets, enteral feeding, infusion volumes, and infusion energies were extracted. The maximum observation period was 28 days prior to patient death.

RESULTS

A total of 12,908 patients were included in our analysis. The proportion of patients without dietary or enteral nutrition increased closer to their dates of death. Observations were recorded at 28 (18.9%), 21 (20.9%), 14 (24.6%), 7 (33.0%), and 0 (80.2%) days prior to death. The infusion volumes given to the patients, as well as their energy contents, decreased near death (P-value for the trend <0.001).

CONCLUSIONS

Our study revealed the current status of nutritional therapy for patients with terminal cancer in Japan. The number of patients receiving only parenteral nutrition increased near death, while the amount of nutritional intake was low.

Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study

OBJECTIVE

Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan.

METHODS

Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries.

RESULTS

A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001).

CONCLUSIONS

Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.

Use of artificial nutrition near the end of life: Results from a French national population-based study of hospitalized cancer patients

Background

The use of artificial nutrition, defined as a medical treatment that allows a non‐oral mechanical feeding, for cancer patients with limited life expectancy is deemed nonbeneficial. High‐quality evidence about the use of artificial nutrition near the end of life is lacking. This study aimed (a) to quantify the use of artificial nutrition near the end‐of‐life, and (b) to identify the factors associated with the use of artificial nutrition.

Methods

This was a retrospective cohort study of decedents based on data from the French national hospital database. The study population included adult cancer patients who died in hospitals in France between 2013 and 2016 and defined to be in a palliative condition. Use of artificial nutrition during the last 7 days before death was the primary endpoint.

Results

A total of 398 822 patients were included. The median duration of the last hospital stay was 10 (interquartile range, 4‐21) days. The artificial nutrition was used for 11 723 (2.9%) during the last 7 days before death. Being a man, younger, having digestive cancers, metastasis, comorbidities, malnutrition, absence of dementia, and palliative care use were the main factors associated to the use of artificial nutrition.

Conclusion

This study indicates that the use of artificial nutrition near the end of life is in keeping with current clinical guidelines. The identification of factors associated with the use of artificial nutrition, such as cancer localization, presence of comorbidities or specific symptoms, may help to better manage its use.

Critical Care Nurses' Perceptions of Parenteral and Enteral Nutrition at the End-of-Life in South Korea

PURPOSE

The purpose of this study was to explore the perceptions of critical care nurses regarding the withdrawal or withholding of enteral nutrition (EN) and parenteral nutrition (PN) at the end-of-life, which is not allowed according to the current law in South Korea.

METHODS

This was a cross-sectional study utilizing a self-report survey. The participants in the study were 141 nurses working in the intensive care units of a tertiary university hospital. The critical care nurses' general attitudes about EN and PN at the end-of-life were measured using the questionnaires developed by Lubart, Leibovitz, and Habot. The nurses responded to additional questions on whether withdrawal or withholding of EN or PN at the end-of-life should be legally allowed.

RESULTS

The mean scores of the general attitude items on EN ranged between 3.03 and 3.35 on a 5-point Likert scale where a value of 1 represents "strongly disagree" and a value of 5 represents "strongly agree," while those for PN ranged between 2.89 and 3.65. Respecting attitudes toward EN and PN, critical care nurses had more negative attitudes about stopping PN than EN. Regarding attitudes about whether patients should be legally able to refuse EN, 34.3% agreed, while 25.7% disagreed. For PN, 40.0% agreed, while 24.3% disagreed.

CONCLUSION

Discussions about making the withdrawal and withholding of artificial nutrition legal should be initiated. Moreover, education regarding evidence about the outcomes of EN and PN during end-of-life care and up-to-date clinical guidelines about it should be provided.

Is parenteral hydration beneficial in terminally ill cancer patients?

INTRODUCTION

It is common for terminally ill patients to have a reduced fluid intake, which often results in a need for more medical support. However, it is not clear if this measure has a real clinical impact.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews including 51 studies overall, from which three were randomized trials. We concluded the administration of parenteral hydration might make little or no difference in terms of survival and quality of life in terminally ill cancer patients, and that it is not clear whether it has any other benefit because the certainty of the evidence is very low.

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death.

Medium-chain triglycerides/long-chain triglycerides versus long-chain triglycerides in treatment of cancer patients with major body mass loss. Survival in patients with refractory cachexia

Introduction

Currently there are no established guidelines regarding the use of long-chain triglycerides (LCT) vs. medium-chain triglycerides medium-chain triglycerides (MCT)/long-chain triglycerides (LCT) in total parenteral nutrition (TPN). Severe malnutrition of patients with refractory cachexia (RC) often causes their disqualification from invasive methods of treatment thus decreasing their quality of life and survival time.

Aim

To compare the changes in nutritional state of patients with RC receiving PN with LCT and LCT/MCT lipid emulsions and to assess the influence of enteral nutrition on their survival time.

Material and methods

The study group comprised of 50 patients (23 female, 27 male) with a median age of 66 years. Refractory cachexia was diagnosed in them due to dysphagia secondary to solid tumours causing obstruction of the gastrointestinal tract (GT). All patients were qualified for surgical gastrostomy due to contraindications to percutaneous endoscopic gastrostomy. The patients were randomly assigned into one of two groups and perioperatively received either LCT or LCT/MCT. Blood samples were collected four times and tested for: total protein, albumin, prealbumin, and C-reactive protein concentration. Patients received Home Enteral Nutrition after discharge from hospital.

Results

Changes in nutritional status parameters were similar among patients receiving lipid emulsions LCT vs. MCT/LCT in TPN for 11 days. The mean survival time of all patients operated to gain enteral access to nutrition was 192 ±268 days, and the median survival was 98 days.

Conclusions

Regarding the short-term TPN, the results of the study do not demonstrate any superiority of MCT/LCT lipid emulsions over LCT, or vice versa. The inability to eat significantly accelerates unintended body mass loss among patients with RC. Disqualification from invasive treatment options deprives some patients of the benefits they might have obtained from the surgical access to GT and enteral nutrition.

Parenteral nutrition at the palliative phase of advanced cancer: the ALIM-K study protocol for a randomized controlled trial

BACKGROUND

Malnutrition is a common complication in patients at the palliative stage of cancer. During the curative phase of cancer, optimal enteral or parenteral nutrition intake can reduce morbidity and mortality, and improve quality of life. When the main goal of treatment becomes palliative, introduction of artificial nutrition is controversial. Although scientific societies do not recommend the introduction of artificial nutrition in all cases of malnutrition, especially in hypophagic patients if their life expectancy is shorter than 2 months, considerable differences in the use of parenteral nutrition in nonsurgical oncology practice are noted around the world. One explanation is a paucity of well-conducted randomized controlled trials in these situations, and consequently, the risk/benefit ratio of parenteral nutrition and its impact on quality of life in palliative care remains uncertain.

METHODS/DESIGN

The ALIM-K study is a French national multicenter randomized controlled trial designed to evaluate the effectiveness of parenteral nutrition, versus an exclusive oral-feeding supply, on the quality of life of malnourished patients who have a functional digestive tube and who are at the palliative phase of advanced cancer with a life expectancy of more than 2 months.

DISCUSSION

This article presents the methodologic options chosen for our study, and in particular, the choice of the Zelen method of randomization, the definition of the main end point (quality of life), the choice of comparator (oral feeding), and the inclusion criteria (life expectancy of more than 2 months), which are all critical points in building a randomized controlled trial in the setting of palliative care.

TRIAL REGISTRATION

This study was registered with the clinical trials database ClinicalTrials.gov on May 27, 2014, under the number NCT02151214.

Artificial Hydration at the end of Life in an Oncology Ward in Singapore

Aim:

The objective of this study has been to examine the frequency of use of artificial hydration in terminally ill cancer patients during the last 48 h of life and the occurrence of symptoms specific to hydration status. Other objectives were to find out if artificial hydration has any impact on survival or had any influence on the patterns of use of opioids and sedatives while under palliative care.

Materials and Methods:

Retrospective review of case notes of palliative care patients who died in a 95 bedded oncology ward was done. Information on demographic profile, duration of palliative care, medication use and on symptoms related to hydration status was collected. Patients on artificial hydration were compared to those who were not on artificial hydration for the above parameters. Survival curves were plotted for both groups using Kaplan-Meier method.

Results:

There were 238 patients of which 55.5% were females. The median age was 62 years and the median duration of palliative care was five days. Artificial hydration was given to 59.2% of patients. There was no significant difference in the incidence of symptoms related to hydration status or in the patterns of medication use between patients who received artificial hydration and those who did not. Kaplan-Meier survival curves did not show any significant survival difference (P value=0.9) between the two groups.

Conclusion:

Artificial hydration during the last 48 h of life did not have any significant impact on symptoms related to hydration status, medication use or on survival in terminally ill cancer patients under palliative care.

[Bioethics and nutrition in adult patients with cancer in palliative care]

Cancer constitutes a major group of chronic diseases and is the second leading cause of death in the developed countries. Palliative care proposes to offer comprehensive support to control symptoms and improve quality of life for patients and their families. Nutrition is an important tool in palliative care, helping patients with their physical, psychological, and social issues and promoting comfort and quality of life. However, in the context of palliative care, nutritional support rarely achieves its role of fully recovering and assuring nutritional status. At this point, the nutritionist must consider the individual patient's needs, preferences, and eating habits, which are essential both for controlling symptoms and assuring satisfaction and comfort. The impossibility of conventionally applying established management and the development of a new perception of the patient often raise dilemmas for professional nutritionists.

Prevailing Ethical Dilemmas in Terminal Care for Patients With Cancer in Taiwan

Purpose

The study aimed to investigate prevailing ethical dilemmas in terminal care for patients with cancer nationwide and identify related factors after the enactment of the Natural Death Act in Taiwan.

Methods

This multicenter study surveyed 800 physicians and nursing staff of oncology wards and hospices through a set questionnaire. A total of 505 respondents (63.1%) who had taken care of patients with terminal cancer were analyzed.

Results

The most frequently encountered ethical dilemmas were truth-telling (mean ± SD = 1.30 ± 0.63; range [never, occasional, often], 0 to 2) and place of care (1.19 ± 0.69), both of which were related to communication issues. Dilemmas related to clinical management were artificial nutrition and hydration (1.04 ± 0.66) and use of antimicrobial agents (0.94 ± 0.70). Logistic regression analyses revealed that positive attitudes about the Natural Death Act was negatively related to the extent of ethical dilemmas (odds ratio, 0.426; 95% CI, 0.256 to 0.710].

Conclusion

The enactment of the Natural Death Act in Taiwan would contribute to improving the quality of end-of-life care, which suggests that this kind of law should be adopted in other countries. Educating cancer care professionals in building positive beliefs toward the act is strongly encouraged.