Chapter 19 Palliative Care: End of Life

BOX 19.2 Suggested Reasons for Referral to an Registered Dietitian Nutritionist

Physiological Intake Issues ●

● ● ● ● ● ●

presence of tube feeding or total parenteral nutrition

concerns about weight loss concerns about weight gain

difficulty with oral intake due to mouth sores, dysphagia, or poor dentition

concerns with continued loss of appetite inadequate fluid intake

client or family would like additional nutri- tion suggestions

Clinical Issues ●

● ● ● presence of wounds

● uncontrolled diabetes end-stage renal disease

end-stage liver disease (with or without encephalopathy)

symptoms not controlled by medications, such as nausea, vomiting, diarrhea, constipation, dyspepsia, or fluid accumulation

● ● ●

intestinal obstruction, when oral intake is not contraindicated

chronic bleeding with weakness

client taking alternative nutrition therapies, such as herbs or supplements

Psychological/Social Issues ●

● ● ● ● ● conflicts regarding the use of food and drink

client or caregiver difficulty giving up past diet restrictions

issues concerning initiating, withholding, or withdrawing nutrition support

client or caregiver needing clarification on dehydration issue

financial difficulties affecting intake living conditions affecting intake

Integrating Nutrition into the Plan of Care

After the information from the nutrition assessment tool is collected and assessed, and the client and family concerns have been identified, a nutrition problem list can be delineated. Nutrition goals that are consistent with other medical and nursing goals should then be established. After the delineation of appropriate pallia- tive nutrition therapies, the problems, goals, and thera- pies are written into the plan of care (6).

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The ethnic, cultural, and religious background of the client and family must be taken into consideration when identifying goals and suggesting appropriate therapies (2). Despite the hazard of applying stereo- types to individual clients, people of various back- grounds have different views and respond differently to food, symptoms, pain, health care–delivery systems, and dying. Older adults also differ from younger adults in their views of death and dying (16), as shown in Box 19.3 (see page 272). The views and responses of others are often greatly different from our own. To be helpful to clients and their families, health care provid- ers must not only recognize that individual differences exist but also be supportive of these differences (17). Many sources are available to assist in understanding ethnic considerations in end-of-life care (18-23).

Counseling Clients with Cancer The client with cancer is generally highly motivated after deciding to implement therapeutic interventions for a terminal illness. Therefore, after minimizing the client’s and family’s guilt about the illness, O’Sullivan Maillet recommends that health care professionals should focus attention on the current diet—how the client is eating and what changes may be appropriately made (8). The value of proper nutrition in promoting overall good health and physical well-being should be emphasized but not overpromised. Teach the client that diet cannot cure the terminal illness and that, regard- less of diet, an illness that is in remission can recur (8). Nutrition quackery is tempting to clients at this point. The RDN’s responsibility is to provide facts without being judgmental and to advise the client as to whether the contemplated therapy is potentially injurious to health. As with any counseling, however, the client makes the final decision, and the decision should be respected even if the dietetics practitioner disagrees with it (8,24).

During the time of cancer therapy, the RDN should help the client and family focus their dietary concerns on meeting immediate needs for energy, protein, vitamins, minerals, and fluid. Clients some- times have trouble understanding why an energy-dense diet that may be high in fat, protein, and carbohydrate is different from a prevention diet, which they may consider to be low in fat and high in fruits, vegetables, and whole grains.

During active cancer therapy, nutrition is often one of the only areas over which the client feels control. The ability of the client to manipulate intake to consume sufficient calories brings a great sense of accomplishment. Courage and determination to survive are often reflected in the client’s efforts to eat well despite symptoms (8). If clients know that they