Objectives: High-protein parenteral nutrition (PN) has been developed to counteract muscle loss in patients with cancer treated with PN. Nevertheless, it is not clear if high-protein PN is as safe as standard PN in patients with palliative cancer. Our primary aim was to compare the proportion of patients with elevated liver enzymes between high-protein and standard PN in patients with palliative cancer enrolled to Medical Home Care. Our secondary aim was to compare the two treatments with regard to weight and albumin levels during treatment.
Methods: Medical records from 2016 to 2018 were retrospectively reviewed to identify palliative cancer patients that had received PN for more than 3 weeks. Data on weight, height, albumin, liver enzymes, socioeconomic factors and dietitian consultations were collected at baseline and after 3–8 weeks of PN treatment. The odds of having elevated liver enzymes or having a maintained weight and/or stable albumin levels were calculated using logistic regression.
Results: 20 patients treated with high-protein PN were compared with 104 patients treated with standard PN. Patients treated with high-protein PN had a significantly higher weight at follow-up compared with patients treated with standard PN (p<0.05). There was no significant difference in the proportion of patients with elevated liver enzymes (OR 0.20; 95% CI 0.02 to 1.86), or maintained weight and/or albumin levels (OR 1.62; 95% CI 0.46 to 5.76) between high-protein and standard PN.
Conclusion: High-protein PN was as safe, and at least as effective, as standard PN to patients with palliative cancer.
The use of home parenteral nutrition (HPN) in patients with incurable cancer remains controversial with significant variation worldwide. We aimed to systematically evaluate the literature from 1960 to 2018 examining the use of HPN in advanced cancer patients for all intestinal failure indications and assess the potential benefits/burdens of HPN in this cohort of patients. The primary end point was survival and secondary end points were quality of life and nutritional/performance status. Meta-analysis was performed with a random effects model, where suitable. Of 493 studies retrieved, 22 met the quality inclusion criteria. Studies were mainly conducted in Western countries (Italy, USA, Canada, Germany), including a total of 3564 patients (mean age 57.8 years). Mean duration for HPN was 5.0 mo. Mean overall survival was 7.3 mo. Patients with improved performance status survived for longer on HPN. Quality of life was sparsely reported though there was no observed negative impact of PN. HPN-related complications were reported in eight studies only and were mainly catheter-related blood stream infections. In conclusion, HPN is used for several indications in advanced cancer, though there is significant heterogeneity of results. Disparities in geographical distribution of the studies may reflect variation in accessing HPN.
Background: Malnutrition worsens health-related quality of life (HRQoL) and the prognosis of patients with advanced cancer. This study aimed to assess the clinical benefits of parenteral nutrition (PN) over oral feeding (OF) for patients with advanced cancer cachexia and without intestinal impairment.
Material and Methods: In this prospective multicentric randomized controlled study, patients with advanced cancer and malnutrition were randomly assigned to optimized nutritional care with or without supplemental PN. Zelen's method was used for randomization to facilitate inclusions. Nutritional and performance status and HRQoL using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL questionnaire were evaluated at baseline and monthly until death. Primary endpoint was HRQoL deterioration-free survival (DFS) defined as a definitive deterioration of =10 points compared with baseline, or death.
Results: Among the 148 randomized patients, 48 patients were in the experimental arm with PN, 63 patients were in the control arm with OF only, and 37 patients were not included because of early withdrawal or refused consent. In an intent to treat analysis, there was no difference in HRQoL DFS between the PN arm or OF arm for the three targeted dimensions: global health (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.88–1.94; p = .18), physical functioning (HR, 1.58; 95% CI, 1.06–2.35; p = .024), and fatigue (HR, 1.19; 95% CI, 0.80–1.77; p = .40); there was a negative trend for overall survival among patients in the PN arm. In as treated analysis, serious adverse events (mainly infectious) were more frequent in the PN arm than in the OF arm (p = .01).
Conclusion: PN improved neither HRQoL nor survival and induced more serious adverse events than OF among patients with advanced cancer and malnutrition.
Clinical trial identification number. NCT02151214
Implications for Practice: This clinical trial showed that parenteral nutrition improved neither quality of life nor survival and generated more serious adverse events than oral feeding only among patients with advanced cancer cachexia and no intestinal impairment. Parenteral nutrition should not be prescribed for patients with advanced cancer, cachexia, and no intestinal failure when life expectancy is shorter than 3 months. Further studies are needed to assess the useful period with a potential benefit of artificial nutrition for patients with advanced cancer.
CONTEXT: There has been a growing consensus that parenteral nutrition and hydration is to be forgone in terminally ill patients with cancer. However, it remains unclear what the beliefs and perceptions of parenteral nutrition and hydration by the family members are.
OBJECTIVES: To clarify their beliefs and perceptions and to examine the relationships between the factors of family members, their beliefs and perceptions, and their overall satisfaction with the care the patient received at the place of death.
METHODS: This study was performed as a part of the cross-sectional anonymous nationwide survey of the bereaved family members of cancer patients in Japan.
RESULTS: In total, 1001 questionnaires were sent and 610 were returned. Among these, 499 were analyzed. Regarding the prevalence of beliefs and perceptions about parenteral nutrition and hydration, 'When a patient cannot eat enough, parenteral hydration is needed' was the highest (87.7%), followed by 'The opinions of medical staff are important in the issue of parenteral nutrition and hydration', 'Parenteral hydration serves as a substitute for oral hydration', and 'If I were a patient and could not eat enough, parenteral hydration would be needed' (85.1, 81.0, and 80.0%, respectively). We extracted two concepts as follows: 'Belief that parenteral nutrition and hydration are beneficial' and 'Perceived need for parenteral nutrition and hydration'. They were not identified as independent determinants of overall care satisfaction.
CONCLUSION: This study showed that beliefs and perceptions about parenteral nutrition and hydration were important in the family members in palliative care.
Background: Malnutrition is a problem in advanced cancer, particularly ovarian cancer where malignant bowel obstruction (MBO) is a frequent complication. Parenteral nutrition is the only way these patients can received adequate nutrition and is a principal indication for palliative home parenteral nutrition (HPN). Giving HPN is contentious as it may increase the burden on patients. This study investigates patients’ and family caregivers’ experiences of HPN, alongside nutritional status and survival in patients with ovarian cancer and MBO.
Methods: This mixed methods study collected data on participant characteristics, clinical details and body composition using computed tomography (CT) combined with longitudinal in-depth interviews underpinned by phenomenological principles. The cohort comprised 38 women with ovarian cancer and inoperable MBO admitted (10/2016 to 12/ 2017) to a tertiary referral hospital. Longitudinal interviews (n = 57) were carried out with 20 women considered for HPN and 13 of their family caregivers.
Results: Of the 38 women, 32 received parenteral nutrition (PN) in hospital and 17 were discharged on HPN. Nutritional status was poor with 31 of 33 women who had a CT scan having low muscle mass, although 10 were obese. Median overall survival from admission with MBO for all 38 women was 70 days (range 8–506) and for those 17 on HPN was 156 days (range 46–506).
Women experienced HPN as one facet of their illness, but viewed it as a “lifeline” that allowed them to live outside hospital. Nevertheless, HPN treatment came with losses including erosion of normality through an impact on activities of daily living and dealing with the bureaucracy surrounding the process. Family caregivers coped but were often left in an emotionally vulnerable state.
Conclusions: Women and family caregivers reported that the inconvenience and disruption caused by HPN was worth the extended time they had at home.
PURPOSE: The purpose of this study was to explore the perceptions of critical care nurses regarding the withdrawal or withholding of enteral nutrition (EN) and parenteral nutrition (PN) at the end-of-life, which is not allowed according to the current law in South Korea.
METHODS: This was a cross-sectional study utilizing a self-report survey. The participants in the study were 141 nurses working in the intensive care units of a tertiary university hospital. The critical care nurses' general attitudes about EN and PN at the end-of-life were measured using the questionnaires developed by Lubart, Leibovitz, and Habot. The nurses responded to additional questions on whether withdrawal or withholding of EN or PN at the end-of-life should be legally allowed.
RESULTS: The mean scores of the general attitude items on EN ranged between 3.03 and 3.35 on a 5-point Likert scale where a value of 1 represents "strongly disagree" and a value of 5 represents "strongly agree," while those for PN ranged between 2.89 and 3.65. Respecting attitudes toward EN and PN, critical care nurses had more negative attitudes about stopping PN than EN. Regarding attitudes about whether patients should be legally able to refuse EN, 34.3% agreed, while 25.7% disagreed. For PN, 40.0% agreed, while 24.3% disagreed.
CONCLUSION: Discussions about making the withdrawal and withholding of artificial nutrition legal should be initiated. Moreover, education regarding evidence about the outcomes of EN and PN during end-of-life care and up-to-date clinical guidelines about it should be provided.
Objectives: Patients with advanced cancer often suffer from severe malnutrition and gastrointestinal obstruction. This population could benefit from home parenteral nutrition (HPN). The aim of this study was to observe the outcome of patients with advanced cancer patients who were eligible for HPN.
Methods: All patients in the nutrition clinic who received HPN over the past 7 y were included in the present study. We compared patients with advanced cancer with the noncancer population in terms of hospitalization rate and mortality.
Results: Of 221 advanced cancer patients, 153 who had no oral/enteral intake and who received HPN survived. Of these, 35% survived for 6 mo, 27% for 1 y, 18.9% survived 2 y, and 3.9% survived for the 7 y of the follow-up. Hospitalization rate was not significantly different from the noncancer population.
Conclusion: These results show that HPN is a relevant palliative therapy for patients with advanced cancer patients without oral or enteral feeding access.
Etude de cas d'un homme âgé de 43 ans, voyageant beaucoup, atteint d'un cancer des intestins. Les interrogations portent sur la mise en place d'une nutrition parentérale à domicile, la gestion d'une iléostomie, le soutien que peuvent pporter les soignants à la famille (femme et enfant) et comment aider le patient par raport à son image corporelle. Les pistes de réponses se trouvent aux pages 183 et 184.
Since there is little knowledge regarding the quality of life (QoL) of cancer patients on home parenteral nutrition (HPN), we planned a prospective, longitudinal, double-center study to investigate the changes of QoL in these patients. One hundred and eleven adult cancer patients who were candidates for HPN following the indications of the European guidelines were consecutively enrolled. For QoL analysis, EORTC QLQ-C30 questionnaires were filled at the HPN start and after 1, 2, 3, and 4 months, and scores changes over time were analyzed according to the univariate mixed-effects linear model for repeated measures. Most patients had gastrointestinal cancers, were severely malnourished, and were in stage IV; two-thirds were still receiving oncologic treatments. Median weight loss over 3 months and body mass index were 11.7% and 20.7, respectively. Median survival was 4.7 (1-42) months; 67 and 34% of patients survived 3 and 6 months, respectively. Global QoL, physical functioning, role functioning, emotional functioning, appetite loss, and fatigue scores had a statistically significant trend over time (P < 0.001, P < 0.001, P = 0.007, P < 0.001, P = 0.004, P = 0.022, respectively). At the univariate analyses, the determinants significantly associated with changes in trend over time for physical, role, and emotional functioning were oncologic treatments (P < 0.001, P = 0.014, P = 0.040, respectively) and for appetite loss they were weight loss and Karnofsky performance status (P = 0.003, P = 0.023, respectively). Global QoL, physical, role, and emotional functioning improved during HPN even in advanced cancer patients on oncologic treatments.
PURPOSE: Few studies have investigated the need for nutritional support in advanced cancer patients in palliative care settings. Therefore, we conducted a questionnaire to examine the relationship between the perception of need for nutritional support and cancer cachexia and the prevalence of specific needs, perceptions, and beliefs in nutritional support.
METHODS: We conducted a questionnaire in palliative care settings. Patients were classified into two groups: (1) non-cachexia/pre-cachexia and (2) cachexia/refractory cachexia.
RESULTS: A total of 117 out of 121 patients responded (96.7%). A significant difference was observed in the need for nutritional support between the groups: non-cachexia/pre-cachexia (32.7%) and cachexia/refractory cachexia (53.6%) (p = 0.031). The specific needs of patients requiring nutritional support were nutritional counseling (93.8%), ideas to improve food intake (87.5%), oral nutritional supplements (83.0%), parenteral nutrition and hydration (77.1%), and tube feeding (22.9%). The top perceptions regarding the best time to receive nutritional support and the best medical staff to provide nutritional support were “when anorexia, weight loss, and muscle weakness become apparent” (48.6%) and “nutritional support team” (67.3%), respectively. The top three beliefs of nutritional treatments were “I do not wish to receive tube feeding” (78.6%), “parenteral nutrition and hydration are essential” (60.7%), and “parenteral hydration is essential” (59.6%).
CONCLUSIONS: Patients with cancer cachexia expressed a greater need for nutritional support. They wished to receive nutritional support from medical staff when they become unable to take sufficient nourishment orally and the negative impact of cachexia becomes apparent. Most patients wished to receive parenteral nutrition and hydration.
Malnourishment is common in cancer patients. Resultant sarcopenia, seen alongside advanced disease, leads to increased rates of perioperative complications, increased rates of infection and decreased tolerance of anti-cancer treatment. A subset of these patients are unable to maintain enteral nutrition, for instance those with bowel obstruction, and improving nutrition in this group is an area of expanding interest. Since the establishment of home parenteral nutrition (HPN), its use in cancer patients in the UK has increased annually (British Artificial Nutrition Survey 2015).
Background and aims: Home parenteral nutrition (HPN) for palliation has little evidence supporting existing guidance. Patient selection remains challenging. We aimed to evaluate use of palliative HPN in our service against ESPEN guidance, and to identify potential prognostic indicators.
Methods: Palliative care patients commenced on HPN were identified. Medical notes, computer records and HPN database were accessed to identify patient demographics, primary diagnosis and aetiology of intestinal failure, blood test results potentially associated with prognosis (eGFR, albumin, CRP, Hb), presence of ascites, and PN duration. By dichotomising blood results Kaplan–Meier survival plots were derived to identify potential associations with survival.
Results: From the HPN database of 111 patients, 20 (18%) were identified as palliative. Six were male (30%), median age (interquartile range (IQR)) 56.4 (51.5–66.8) years. Four patients commenced palliative HPN between 2000 and 2006, while 2007–2013 there were 16. The median number (IQR) of nights on HPN was 85 (19–352). The most common indication was gastro-intestinal obstruction (n = 13, 65%) and short bowel syndrome following palliative surgical resection (n = 4, 20%). Kaplan–Meier survival plots identified worse prognosis on HPN if the presenting albumin was =30 g/L p = 0.016.
Conclusion: The use of HPN in palliative care is increasing. Current patient selection meets with ESPEN guidance with respect to aetiology of intestinal failure and length of survival on PN. We suggest that a low albumin (not a marker of malnutrition) may help to predict those who are likely to survive less long on palliative HPN. A multi-centre prospective study, also examining quality of life would help define improved guidance.
"Shirley" is a 60-year-old woman who presented with abdominal pain and distension 10 years ago. Following a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy she had been diagnosed with an International Federation of Gynecology and Obstetrics stage IC poorly differentiated endometrioid cancer of the ovary and had subsequently received six cycles of carboplatin, cyclophosphamide, doxorubicin, and ifosfamide. She was well until 3 years ago, when a computed tomography scan showed extensive disease in the omentum and pelvis.A laparotomy revealed inoperable intra-abdominal disease that was histologically consistent with recurrent ovarian cancer. She received six cycles of carboplatin and paclitaxel. A computed tomography scan confirmed a partial response, and Shirley remained well until 2 years ago. At that time, she developed abdominal distension, colic, and atulence, due to progressive disease. She was treated with single agent carboplatin, but after two cycles, Shirley presented with the symptoms and signs of bowel obstruction. Surgical management was not an option, given the extent of the intra-abdominal disease. Nausea and abdominal discomfort were well controlled medically, and she reported a good quality of life, although she vomited after eating. Following a series of long discussions with Shirley, her relatives, nursing staff, and a number of physicians,a percutaneous venting jejunostomy was fashioned to permit her to eat and drink. At this point, Shirley and her medical team began to consider whether intravenous nutritional support should be initiated.
Les auteurs font la synthèse qui a pour objet de préciser la place de la nutrition parentérale en soins palliatifs, en particulier en ce qui concerne ses indications, ses modalités de prescriptions et les risques associés.
Une grande attention est portée à l'alimentation de la personne en fin de vie. L'auteur explore les raisons possibles de cette attention et ce qu'elle implique pour le patient, ses proches et les soignants.
Les thèmes abordés, lors de cette journée, permettent d’embrasser un large panel de réflexions, autour du nourrir en fin de vie, de l’obstination déraisonnable des soins avec le douloureux problème de l’arrêt de l’hydratation et de la nutrition. Quel sens donner à l’acte nourricier terminal ? Quelle place pour le goût et les sens dans cet espace-temps qui n’en est pas dénué ? Les différents thèmes abordés, à la fois en séances plénières et en ateliers, permettent à chacun de se projeter, au-delà du soin, au-delà de l’accompagnement, au-delà du nourrir. La démarche palliative prend ici tout son sens et l’approche multidisciplinaire redonne du sens à l’acte du nourrir et aussi à son arrêt.
[Adapté Résumé Comité scientifique]
L’arrêt de la nutrition artificielle chez le sujet en fin de vie est une décision complexe en raison de la nécessité d’analyse concomitante de nombreux facteurs intriqués d’ordre physiologique, clinique, biologique, pronostique, symbolique, éthique…
Méthode : les auteurs ont réalisé une enquête auprès des soignants du CHR Metz-Thionville, exerçant dans les services de médecine, chirurgie et réanimation, afin de recueillir leurs opinions, vécus et ressentis face à l’arrêt de la nutrition artificielle.
Résultats et discussion : La problématique de l’arrêt de la nutrition artificielle n’est pas circonscrite aux services de soins palliatifs puisque près de 64% des soignants y ont déjà été confrontés. Les difficultés émotionnelles principalement décrites sont un sentiment d’impuissance
et un manque d’aisance face au patient et à ses proches. Deux tiers des soignants pensent que la nutrition artificielle n’est pas indispensable au confort, pourtant le bien-être du patient reste une de leurs préoccupations principales. Près de 80% des soignants se trouvent insuffisamment informés sur la nutrition artificielle en fin de vie et environ 90% souhaiteraient une formation complémentaire sur le sujet.
Conclusion : Aider les soignants à créer des temps de réflexion pluridisciplinaire avec une analyse globale de la situation du patient semble une étape importante. En complément, la diffusion
d’informations sur la nutrition artificielle en soins palliatifs, sous forme d’ateliers de travail ou encore de fiches de synthèse, doit être réfléchie afin d’améliorer les connaissances, le ressenti, l’aisance des soignants, et par conséquent la prise en charge du patient en fin de vie.
L’indication d’une nutrition parentérale en soins palliatifs est fonction de nombreux paramètres. Du point de vue médical, la nutrition parentérale a un effet bénéfique, en terme de qualité de vie, d’indice de performance et de survie, chez le patient en soins palliatifs s’il en bénéficie plus d’un mois. Notre travail consiste en une étude de l’alimentation parentérale
dans l’unité de soins palliatifs du CHU de Nancy, de son utilisation et des questionnements qu’elle soulève basée sur une analyse de la littérature et sur une étude rétrospective des prises de décision concernant la nutrition parentérale dans l’unité (son initiation, son maintien, ses conditions de mise en oeuvre et son arrêt). Nous proposons un arbre d’aide à la décision de mise en place ou d’arrêt de la nutrition parentérale en soins palliatifs. Les patients, leurs proches et les soignants doivent avoir conscience que c’est la pathologie principale qui conduit au décès. Les buts et les limites de la nutrition artificielle doivent être bien compris de tous, afin de prévenir des espoirs de bénéfices irréalistes ou des incompréhensions soulevées par l’arrêt de celle-ci. Dans le contexte des soins palliatifs, pour toutes prescriptions en rapport avec la nutrition parentérale, une réflexion d’équipe pluridisciplinaire centrée sur le
patient et ses désirs doit en être le guide.
Dans ces réunions bibliographiques, il est question de : "la limitation et l'arrêt des traitements aux Urgences", "les douleurs neuropathiques", "Administration sous-cutanée d'antibiotiques" et "Physiologie du mourir : sécrétion accrue d'ADH en fin de vie" à l'hôpital Cognacq-Jay à Paris.