Nutrition in palliative care: issues, perceptions and opportunities to improve care for patients

The Role of Registered Dietitians in Cancer Palliative Care: Responsibilities, Challenges, and Interdisciplinary Collaboration-A Cross-Sectional Survey

Registered dietitians (RDs) in palliative care help maintain patients' quality of life by providing personalized nutritional support that alleviates eating-related distress. This study aimed to clarify the role of RDs in palliative care by examining their responsibilities and challenges in caring for cancer patients. A nationwide mailed survey was conducted in 2022, focusing on RDs involved in cancer palliative care. One RD per facility was included from all 501 hospitals accredited by Japan's Ministry of Health, Labour and Welfare. Multivariate analysis identified factors related to collaboration with palliative care teams and challenges in cancer care. Responses from 325 RDs (63.9%) across 325 hospitals (63.9%) were analyzed. Among RDs who consistently collaborated with the palliative care team (PCT), significant associations (p < 0.05) were found with exclusive engagement in cancer/palliative care, providing nutritional counseling to inpatients, the frequency of ward rounds, and individualized meal provision. Challenges included the following: "I struggled with determining appropriate food choices for patients unable to eat", and "Metabolic complications like cachexia hindered my ability to provide adequate support". RDs play a crucial role in providing individualized meals for cancer patients through PCT collaboration and ward rounds. To ensure effective support in challenging situations, RDs must be exclusively engaged in palliative care and receive specialized education.

Nutrition in Advanced Disease and End of Life Cancer Care

OBJECTIVES

This paper addresses nutritional challenges in advanced cancer and at the end of life and implications for oncology nursing practice.

METHODS

Recent literature and position statements regarding nutritional support in advanced disease and at the end of life were reviewed and case studies were developed to illustrate the nutritional issues facing patients and family members.

RESULTS

The literature and case examples illustrate the many issues confronting patients, families, and clinicians related to nutritional support including balancing the goals of comfort versus prolonged survival. Patients and families often face difficult decisions regarding the use of medically assisted nutrition and hydration while considering potential burdens and harms. Principles of ethics can be applied in the process of making these decisions.

CONCLUSIONS

Providing nutrition is one of the most important aspects of care provided by families for patients with advanced disease with deep meaning in these relationships, especially at the end of life. Oncology nurses provide valuable guidance in these decisions and offer support to both patients and families to ensure quality of life across the trajectory of cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can apply skills in patient and family caregiver education, communication, and support to help navigate nutritional decisions.

The ethics of clinically assisted nutrition and hydration in adults and the role of the advanced clinical practitioner

Clinically assisted nutrition and hydration (CANH) decision-making in adult patients presents complex ethical dilemmas that require careful consideration and navigation. This clinical review addresses the multifaceted aspects of CANH, emphasising the importance of ethical frameworks and the role of advanced clinical practitioners (ACPs) in guiding decision-making processes. The pivotal role of ACPs is highlighted, from their responsibilities and challenges in decision-making to the collaborative approach they facilitate involving patients, families and multidisciplinary teams. The article also explores ethical principles such as autonomy, beneficence, non-maleficence, and justice, elucidating their application in CANH decision-making. Legal and ethical frameworks covering CANH are examined, alongside case studies illustrating ethical dilemmas and resolutions. Patient-centred approaches to CANH decision-making are discussed, emphasising effective communication and consideration of cultural and religious beliefs. End-of-life considerations and palliative care in CANH are also examined, including the transition to palliative care and ethical considerations in withdrawal or withholding of CANH. Future directions for research and implications for clinical practice are outlined, highlighting the need for ongoing ethical reflection and the integration of ACPs in CANH decision-making.

Malnutrition management and the application of medical nutrition therapy in hospitalized patients at the end of life

OBJECTIVES

(1) To determine the prevalence of malnutrition risk in hospitalized patients at the end of life (EOL), (2) to evaluate which nutritional interventions are administered in hospitalized end-of-life patients with malnutrition risk and (3) to assess the association of end-of-life care and the administration of medical nutrition therapy in patients with malnutrition risk.

DESIGN

Cross-sectional multi-center study SETTING: Hospital PARTICIPANTS: Hospitalized adult patients MEASUREMENTS: Based on the valid and reliable questionnaire of the Nursing Quality Measurement 2.0 (LPZ), the parameters of demographic data, medical diagnoses, end-of-life phase, care dependency, malnutrition risk according to the Malnutrition Universal Screening Tool (MUST) and nutritional interventions conducted in patients at risk of malnutrition were assessed. Descriptive statistics and statistical tests were conducted. Logistic regression models were established to identify odds ratios (OR) and confidence intervals (CI) for the association of end-of-life care and the provision of medical nutrition therapy. This was done separately for oral nutritional supplements (ONS), enteral nutrition and parenteral nutrition as the respective dependent variables.

RESULTS

Of all 12,947 participants, 706 (5.5%) were in an end-of-life phase. The prevalence of malnutrition risk in end-of-life patients was 41.1% compared to 24.7% in other patients (p < 0.001). End-of-life patients with malnutrition risk received more nutritional interventions than other patients with malnutrition risk. The regression models showed that being at the end of life (CI 1.30, 2.63; p < 0.001), being treated by a dietitian (OR 6.02; CI 4.86, 7.45; p < 0.001), suffering from dementia (OR 1.85; CI 1.10, 3.12; p = 0.02) or cancer (OR 1.56; CI 1.25, 1.96; p < 0.001) increased the chance of receiving oral nutritional supplements. For receiving parenteral nutrition, being at the end of life (OR 1.68; CI 1.04, 2.71; p = 0.04), being treated by a dietitian (OR 5.80; CI 4.07, 8.25; p < 0.001), surgery within the previous two weeks (OR 1.58; CI 1.09, 2.30; p = 0.02), younger age (OR 0.99; CI 0.98, 1.00; p = 0.04), care dependency (OR 0.97; CI 0.96, 0.98; p < 0.001), suffering from a disease of the digestive system (OR 2.92; CI 2.07, 4.11; p < 0.001) or cancer (OR 2.44; CI 1.71, 3.49; p < 0.001) were independent predictors. Being at the end of life did not influence the application of enteral nutrition.

CONCLUSION

This study showed that nutritional interventions are often applied in end-of-life patients admitted to general hospitals. Being at the end of life was positively associated with the application of oral nutritional supplementation and parenteral nutrition. This data does not allow a conclusion about the appropriateness of using medical nutrition therapy in this study sample. Judging the appropriateness of medical nutrition therapy at the end of life is challenging because of the high variability of prognostication as well as the wishes and needs of the specific patients and their relatives that influences the appraisal of adequate interventions. Every decision about nutrition and hydration in end-of-life patients should be a shared decision and be based on advanced care planning principles.

A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life

"End of life" is a stage defined by the existence of an irreversible prognosis that ends with a person's death. One of the aspects of interest regarding end of life focuses on parenteral nutrition, which is usually administered in order to avoid malnutrition and associated complications. However, parenteral nutrition can be adapted to specific circumstances and evolve in its functionality through supplementation with certain nutrients that can have a beneficial effect. This narrative review aims to carry out a situation analysis of the role that could be adopted by supplemental parenteral nutrition in attenuating alterations typical of end of life and potential improvement in quality of life.