Chapter 19 Palliative Care: End of Life

feedings to continuous drip, because the former method seems more like a meal than drip delivery via pump. Consider a consult to a speech therapist for evaluation and recommendation. In theory, a continuous drip administration of 100 to 125 mL/h of full-strength (1 kcal/mL) solution is the maximum amount needed for most clients if weight maintenance is the goal (2,400 to 3,000 kcal/d) (43). In practice, it has been found that only 1,000 to 1,800 kcal/d (continuous drip for 10 to 15 hours) may be needed to achieve satiety and comfort. McCamish and Crocker recommend 25 to 30 kcal/kg body weight for the hospice patient whose goal is to maintain or improve strength (44). Greater amounts frequently cause complications, including fluid overload, cramps, diarrhea, reflux, and aspiration (45).

Parenteral Nutrition A case can be made for limited use of TPN in palliative care. When clients are in the early stages of their disease, they are often able to lead full and active lives. TPN may be appropriate for those who are unable to ingest enough energy orally or via enteral tube feeding to sustain their activity level because of a poorly func- tioning or nonfunctioning GI tract (46). Two examples of such medical conditions are inoperable bowel obstruction and short-bowel syndrome.

On the other hand, it has been found through years of experience in hospice care that TPN is generally not well tolerated by the terminally ill, and rarely does par- enteral feeding reduce the distress of anorexia and cachexia when the terminal stage is reached. Instead, TPN may subject the client to new problems such as fluid overload, increased pulmonary and gastric secre- tions requiring suctioning, shortness of breath, pain, and sepsis that are distressing and prolong suffering. If TPN is desired, it is generally best begun in the hospi- tal setting before returning to the home or long-term care facility. Home and nursing facility administration should be closely monitored by a specially trained care team (46).

It has been found that palliative care clients with advanced cancer rarely benefit from aggressive nutri- tion support via tube or parenteral feedings. Those clients who are not pushed to eat and drink if they do not desire to or are unable seem to be at an advantage. However, a previously placed tube for enteral feedings or an intravenous line for TPN may not need to be dis- continued, unless the client desires (35,47).

Food Service Suggestions

Food service in a facility that provides palliative care must reflect the philosophy of maximizing client comfort and enhancing quality of life (48). Menu

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development should reflect the ethnic, cultural, and regional food preferences of the population. Regardless of meal pattern selected (eg, three or four meals, lighter meals, or heavier meals), there must be flexibil- ity for reheating menu items or preparing a quick meal when a client desires. Allowing clients to select menus as close to serving time as possible may help to allay anorexia. Small portions attractively garnished and plated in a dining atmosphere conducive to client and family socialization also contribute to better client meal acceptance. Family members’ assistance with meals further enhances the dining experience. Some clients and families may express a desire for additional fiber, others for low-fat foods, still others for meals that reflect personal nutritional beliefs. Specific dietary modifications, such as low- sodium, low-fat, and diabetic requirements, may be needed. In most cases, however, these restrictions are liberalized to allow maximum pleasure, variety, and choice (9). Fluctuations in mental alertness, level of responsiveness, dental status, and swallowing difficul- ties may indicate the need for consistency modifica- tions such as soft, mechanical soft, pureed, or blenderized foods (48). Simple, easy-to-prepare foods served in smaller portions are often more acceptable to clients than complicated, labor-intensive recipes. Comfort or familiar foods also are enjoyed and may be better tolerated. Some examples of universally selected comfort foods are macaroni and cheese, mashed potatoes and gravy, grilled cheese sandwiches, peanut butter and jelly sandwiches, toast, crackers, soups, fresh fruits, and soft salads.

Inpatient palliative care facilities often provide a family kitchen, including personal china, flatware, and crystal storage; refrigerated storage; and a reheating system to handle foods brought from home (48). A family kitchen allows flexibility for meal service and supports family and friends in their caring efforts. Public health rules for labeling and dating food items and safe storage time limits should be enforced. The importance of food sanitation and safety cannot be overemphasized in a setting in which many clients are immunocompromised. By serving nutritious, attrac- tively prepared food for visual and physical pleasure, the palliative care facility’s food service staff has the opportunity to enrich clients’ lives at a time when the smallest pleasure is truly treasured (48).

ETHICAL AND LEGAL CONSIDERATIONS

The ethical and legal considerations in nutrition support of palliative care clients are increasingly being debated, partly because technological advances in nutrition support enable us to keep people alive beyond