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![]() ![]() Thompson et al examined the coping skills of patients on home enteral nutrition (HEN).13 Successful coping was earmarked by patients’ acceptance of personal responsibility for their attitude and behavior. Winkler and Wetle conducted qualitative interviews on quality of life with three patients on long-term HPN.12 The authors reported that the patients expressed a good quality of life despite the challenges of the technologically complex therapy. Therefore, the anticipated life expectancy for patients with advanced cancer may be a factor to consider when examining HPN’s potential benefit vs. The researchers reported that quality of life was better for patients who received HPN for a minimum of three months. Nutrition support is life sustaining, but does it have a positive impact on a patient’s quality of life? Bozetti and colleagues examined the quality of life for patients with advanced cancer on home parenteral nutrition (HPN).11 The patients were severely malnourished, had limited swallowing ability, and were no longer receiving curative therapy. Home nutrition support can be a lifetime commitment for patients with intestinal failure due to either surgical removal or disease/treatment-related impairment of a portion of the gastrointestinal tract. Nutrition support has been shown to benefit competent patients by reducing physical deterioration, improving quality of life, and preventing the emotional effect of “starving the patient to death.”9 Practice guidelines for palliative care in adults with progressive head and neck cancer reported that tube feeding improved nutrient intake, quality of life, and fluid status.10 ![]() Some studies of patients who are dying have indicated that thirst and hunger are not a significant problem when patients decide to forgo nutrition support and hydration.6,7 A study of nurses caring for terminally ill patients who voluntarily chose to stop food and fluid intake reported the nurses’ median score of the quality of the patients’ deaths as 8 (range: 0 equaled very bad death and 9 equaled very good death).8 For patients with irreversible or terminal illness, it appears that nutrition support may not benefit the patient but may increase suffering and hasten death. Positron emission tomography scans have demonstrated that when a patient is in a persistent vegetative state, the brain areas responsible for pain perception do not function.4 Therefore, providing nutrition support to this patient population to provide comfort and reduce suffering is not science based. The notion that withholding nutrition support contributes to pain and suffering has also been debated. There are considerable data indicating that it is not beneficial to provide nutrition support for patients with an irreversible (permanent vegetative state or advanced dementia) or terminal (death anticipated within six months) illness.2 Seventy prospective randomized controlled trials of nutrition support in cancer patients were reviewed and showed no clinical benefit to this patient population.3 Evidence suggests that providing nutrition support can contribute to increased suffering in terminally ill patients due to increased nausea, vomiting, bleeding, edema, pulmonary edema, incontinence (bladder and bowel), or infections, as well as a potential requirement for patient restraint.2,4,5Ī comprehensive study of nursing home patients with dementia reported that the insertion of feeding tubes did not improve survival over those hand fed, did not lower the risk of aspiration pneumonia, and did not improve pressure ulcer healing, weight status, comfort, or functional status.4 Another study found that nursing home residents with a feeding tube died 1.44 times sooner than those without a feeding tube.5 Guidelines are available that provide timelines for how long clinicians should allow inadequate intake before initiating nutrition support.1 However, the timeline for starting and stopping nutrition support in terminally ill patients is often less clear to the clinician, resulting in angst over what is “the right thing to do.” Nutrition support via a feeding tube or intravenous catheter is a lifesaving therapy for patients who are unable to meet nutrient needs orally. It is adjunctive therapy that enables a patient to meet nutrient needs during curative or palliative therapy. Nutrition support alone does not reverse or cure a disease or injury. ![]() Patricia Fuhrman, MS, RD, LD, FADA, CNSDĬaring for terminally ill patients involves acting ethically and in the individuals’ best interest-a daunting task when patients, families, and health professionals are faced with difficult choices. Nutrition Support at the End of Life: A Critical Decisionīy M. ![]()
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