Nutritional Support

Evidence Summary

Nutrition intervention includes both nutrition counselling and the use of nutritional supplements and artificial nutrition. Artificial nutrition may consist of dietary supplements to be taken orally, enterally (via feeding tube placed within the stomach, duodenum or jejunum), or parenterally. There are significant risks and burdens associated with artificial feeding which increase with the invasiveness of the route chosen. Decisions about artificial nutrition in palliative care, therefore, should include an assessment of both the benefit and burden of all treatments offered. Clinicians often experience difficulty when making decisions about artificial feeding. [1,2]

While the benefit of achieving weight stabilisation in patients who are losing weight is longer survival and improved quality of life when compared to those who continue to lose weight, the timing and optimal strategy for nutritional support is unknown. [3]

Nutritional counselling, repeated professional communication process as distinct from casual advice which may be given to patients, includes assessment, diagnosis and treatment and has been shown to improve some outcomes, including quality of life. [4] Artificial nutrition outcomes have been shown to improve when combined with nutritional counselling. [5]

  

  

  

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Review Collection

EPA (omega 3 fatty acid from fish oil) has been studied as part of a nutritional supplement in patients with cachexia anorexia from pancreatic cancer. Despite promising results in several studies, a systematic review has not shown it to be better at improving weight or quality of life than a nutritional supplement without EPA. [6]

A number of studies examining the benefits of dietary supplements, such as minerals, vitamins and proteins have been undertaken in cancer patients, yet no systematic reviews have established positive recommendations. [7]

Weight loss due to primary cachexia anorexia syndrome from progressive malignancy is not reversed by supplying additional nutrition. [8]

Few studies have examined the impact of medically assisted nutrition on survival or quality of life in palliative care patients [9, 10] or those with dementia. [11] Clinical guidelines for use of artificial nutrition in the palliative care setting are evolving. [12] The proposed guidelines suggest criteria for identifying who might benefit, including nutritional criteria, life expectancy, quality of life, and functional capability. Patients with secondary cachexia (due to obstruction or swallowing difficulties, without the inflammatory processes of the cancer cachexia syndrome) may benefit from a trial of enteral or parenteral nutrition. It should be recognised that artificial feeding has significant risks, complications and burdens. [13]

In patients with advanced dementia and cachexia, artificial feeding (by tube) does not prolong life or prevent aspiration. [14,15] A recent systematic review compared the outcomes of enteral nutrition in dementia and other conditions, and showed similar mortality for patients with dementia and other advanced conditions receiving enteral nutrition. The data included were of variable quality and the issue is acknowledged as ethically challenging. [11]

A systematic review revealed that the frequency of use of artificial nutrition in cancer patients in the last week of life may range from 3 – 53%, and artificial hydration may be used in up to 80%, but withholding or actively withdrawing artificial hydration or nutrition is rarely studied. [16] There was no clear-cut benefit in terms of survival, comfort or quality of life from either treatment. The evidence that it may improve or worsen specific symptoms (thirst, delirium, nausea, fluid overload) is not consistent.

Practice Implications

  • The optimal timing and strategy for providing nutritional support is not known.
  • There is limited evidence about the effects of nutritional counselling on palliative care patients, but non-sustained improvements in intake have been shown. [5]
  • Decisions about artificial nutrition in palliative care patients should include an assessment of both the benefit and burden of all treatments offered.
  • The use of enteral and parenteral nutrition in terminally ill cancer patients approaching the end of life is rarely indicated. Dying patients lose their ability to swallow safely in the last few days of life. Studies support the view that dying patients require only minimal amounts of food and fluids to reduce thirst and hunger. [6,9]
  • The use of enteral and parenteral nutrition in patients with advanced cancer and a life expectancy of months or more is controversial. [8] Clinical guidelines for use of parenteral nutrition in the palliative care setting are evolving and the need to develop evidence to support decision making in this topic is recognised. [12,13]
  • Artificial feeding in advanced dementia is ethically problematic and does not provide good palliation. In general the focus should be on offering whatever oral intake the patient will accept, and on good mouth care. However families and aged care staff may both require support and education in this area. [2,15]
  • Decision-making about artificial nutrition for patients who lack capacity requires a framework that balances treatment risks/benefits /burdens and quality of life considerations, and family and clinician perspectives, with a concern not to prolong suffering. However 'quality of life' is a concept that has varying interpretations, and discussion between clinicians and family needs to aim for a shared understanding. [1]
  1. Clarke G, Harrison K, Holland A, Kuhn I, Barclay S. How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review. PLoS One. 2013 Apr 16;8(4):e61475.
  2. Royal College of Physicians and British Society of Gastroenterology. Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards end of life. London: Royal College of Physicians; 2010.
  3. Davidson W, Ash S, Capra S, Bauer J, Cancer Cachexia Study Group. Weight stabilisation is associated with improved survival duration and quality of life in unresectable pancreatic cancer. Clin Nutr. 2004 Apr;23(2):239-47.
  4. Baldwin C, Spiro A, Ahern R, Emery PW. Oral nutritional interventions in malnourished patients with cancer: a systematic review and meta-analysis. J Natl Cancer Inst. 2012 Mar 7;104(5):371-85. doi: 10.1093/jnci/djr556. Epub 2012 Feb 15.
  5. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017 Feb;36(1):11-48. doi: 10.1016/j.clnu.2016.07.015. Epub 2016 Aug 6.
  6. Ries A, Trottenberg P, Elsner F, Stiel S, Haugen D, Kaasa S, et al. A systematic review on the role of fish oil for the treatment of cachexia in advanced cancer: an EPCRC cachexia guidelines project. Palliat Med. 2012 Jun;26(4):294-304. Epub 2011 Aug 24.
  7. Mochamat, Cuhls H, Marinova M, Kaasa S, Stieber C, Conrad R, et al. A systematic review on the role of vitamins, minerals, proteins, and other supplements for the treatment of cachexia in cancer: a European Palliative Care Research Centre cachexia project. J Cachexia Sarcopenia Muscle. 2017 Feb;8(1):25-39. Epub 2016 Jul 20.
  8. Arends J, Bodoky G, Bozzetti F, Fearon K, Muscariotoli M, Seslga G, et al. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr. 2006 Apr;25(2):245-59. Epub 2006 May 12.
  9. American Society for Parenteral and Enteral Nutrition (ASPEN). Guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients. Section XI: Specific guidelines for disease - adults. JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):61SA-96SA.
  10. Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J. Medically assisted nutrition for adult palliative care patients. Cochrane Database Syst Rev. 2014 Apr 23;(4):CD006274.
  11. Brooke J, Ojo O. Enteral nutrition in dementia: a systematic review. Nutrients. 2015 Apr 3;7(4):2456-68.
  12. Mirhosseini N, Fainsinger RL, Baracos V. Parenteral nutrition in advanced cancer: indications and clinical practice guidelines. J Palliat Med. 2005 Oct;8(5):914-8.
  13. Dy SM, Apostol CC. Evidence-Based approaches to other symptoms in advanced cancer. Cancer J. 2010 Sep-Oct;16(5):507-13.
  14. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70.
  15. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.
  16. Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J, Lundquist G, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Annals Oncol. 2011 Jul;22(7):1478-86. Epub 2011 Jan 3.

Guidelines

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Last updated 08 November 2019