Chapter 19 Palliative Care: End of Life

but needs assistance in knowing what to eat and how to maximize the quality of mealtimes.

HELPING THE CLIENT WHO CANNOT OR WILL NOT EAT

Anorexia and cachexia are common phenomena that occur with clients who are receiving palliative care (26). Tumors and medications may cause the following:

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early satiety, especially with lung, stomach, and pancreatic tumors;

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specific food aversions, with almost all tumors and particularly to protein-containing foods, such as beef and pork;

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nausea and vomiting, especially with liver, gastric, and pancreatic cancers and metastases to the liver and as a result of narcotics and other therapies; and

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decreased interest in foods, particularly with an external tumor compression or partial obstruction of any part of the GI tract (6,27).

Although weight loss is often a worrisome sign, treat- ment does not necessarily improve the client’s well-be- ing or chance of survival (28,29).

Anorexia and cachexia are not always problems to the client and family. When they are problems, gener- ally it is more so for the family than for the client (30). Cachexia may be a problem for clients and families because they do not understand what causes it or how it occurs.

When working with an anxious family of a client who cannot or will not eat, attempts should be made to reduce the stress of not eating, as shown in Boxes 19.4 (see page 274) and 19.5 (see pages 282–283) (17). The family’s anxieties can be diminished and the client can be freed from the pressure to eat when attention is shifted from maintaining the client’s nutritional status to enhancing client comfort through providing small, appetizing meals. Sometimes it is most appropriate to offer no food unless the client requests it. Although this shift may be difficult at first, it brings considerable relief to both client and family in the long run (17). Helpful phrases that have been used successfully to discourage the “he must eat or he will die” mentality include the following (17):

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“The disease controls his appetite; pushing him to eat won’t change the course of the disease.”

● “He’s sick and will be sick even if he eats.” ●

“Pushing him to eat may only make him uncomfortable.”

● “Let him sit with you and eat what he wants.” ●

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“Try not to worry that he eats poorly; it doesn’t seem to bother him.”

DEHYDRATION

Dehydration is a common outcome for the dying patient, and it is often assumed to be uncomfortable by clients and families. To the contrary, when dehydration occurs close to the time of death, it appears to become a natural anesthesia. It decreases the client’s perception of suffering, perhaps by reducing the level of con- sciousness and increasing production of endorphins and dynorphin (31-35). Concomitant dry mouth associ- ated with dehydration can be relieved through ice chips, lubricants, and other simple remedies if it is safe for the patient to swallow (33). Dental sponges with a mixture of olive oil and nonalcohol mouthwash (1:1 ratio) can be used to wet the mouth if swallowing is not safe. If life expectancy is measured in weeks or days, dehydration, as a natural course of events, may be preferred to aggressive nutrition support through tube feedings and/or total parenteral nutrition (TPN), if such feedings cause discomfort. By foregoing aggres- sive therapy, the following conditions may result, which can benefit the client (24,36-37):

● decreased GI and venous distention ●

● ● decreased diarrhea

decreased pulmonary secretions, resulting in less coughing, less fear of choking and drowning, and fewer rattling secretions

● decreased urinary flow and need to void decreased use of restraints

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When life expectancy is longer, fluid intake should be encouraged, and creative ways to increase intake should be implemented, such as varying the flavor and temperature of water and providing liquid nutritional supplements, juices, bouillon, and other liquids. Inadequate fluid intake contributes to constipation, a common problem that detracts from quality of life (6,27). There may also be a role for low-volume intra- venous hydration to increase comfort for clients who manifest symptoms of opioid toxicity (agitated delir- ium, myoclonus, seizures), accompanied as appropriate by switching opioids and use of fewer sedating treat- ments. Hypodermoclysis, or the administration of sub- cutaneous fluids, usually normal saline, can be used to rehydrate or maintain adequate hydration for termi- nally ill patients who have stopped eating and drinking near the end of life. Hypodermoclysis (usually at a rate of 500 to 1,500 mL/24 hours) is noninvasive, safe, and

decreased nausea, vomiting, and potential for aspiration