Nutrition and Hydration
at the
End of Life
Hunter Woodall, MD
Nathan Bradford, MD
AnMed Family Medicine Residency
Anderson, SC
Learning Objectives 1
• Learners will become familiar with the
usual pattern of decline in oral intake at
the end of life.
• Learners will be better prepared to handle
questions about thirst and hunger from
families of dying patients.
Learning Objectives 2
• Learners will be able to discuss the
evidence for and against artificial feeding
at the end of life, particularly in dementia
patients.
• Learners will be introduced to
hypodermoclysis and some of its common
uses at the end of life.
Oral intake declines near the end
• Oral intake can be used to inform
prognosis.
• Patients without oral intake or IV fluids
usually die peacefully in 6–8 days
(range 1–14 days).
The Typical Pattern
• Self feed
• Spoon fed
• Drinks sips/takes bites
• Uses straw mainly for sips
• Small amounts by syringe
• Mouth care only
Hunger and Thirst
• Most dying patients are anorexic and
display little to no appetite
• Many folks want a tiny favorite taste
• When intake slows down, good mouth
care is vital for comfort
• Prepare families and be ready to treat
rattling near the end (more on this later)
(Fast Fact #010 Hallenbeck, 2005)
EXERCISE ONE
FAST FACT # 133
Robin Fainsinger, MD, 2009
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_133.htm
What is the take home message?
FEEDING = LOVE
• Family members will ask about:
• Hunger, thirst, and starvation
• Non-oral hydration or feeding
• NG/PEG
• IVF or even TPN
• Some will equate medical interventions with
normal feeding
(Fast Fact #084 Weissman, 2009; Fast Fact #133 Fainsinger, 2009)
Non-Oral Feeding/Hydration
• Doctors can over-feed as well
• Non-oral hydration is a medical
intervention and can be ethically stopped
or refused
Parenteral Hydration
• Advantages:
•
•
•
•
Can prolong awake time
Can treat or prevent delirium
Comforts families and may buy time
Occasionally needed for essential access
• Disadvantages:
• Peripheral edema
• Troublesome secretions
• Pulmonary edema—breathlessness
(Fast Fact #133 Fainsinger, 2009; Fast Fact #134 Fainsinger, 2009)
EXERCISE TWO
Read Fast Fact #10
James Hallenbeck, MD, 2005
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_010.htm
Did you learn something new?
Dementia and Tube Feeding
• TF can be refused or stopped
• TF in severely demented persons is futile:
• It does not decrease mortality, fix skin
problems, or provide comfort.
• A tube provides medication access but is
usually not necessary for that purpose
(Fast Fact #010 Hallenbeck, 2005)
Treating the Rattling
•
•
•
•
•
•
Be parsimonious with fluids
Positioning
Suction
Atropine or hyoscyamine
Glycopyrrolate
Transderm scopolamine
(Fast Fact #109 Bickel/Arnold, 2009)
Hypodermoclysis
• No more “hunt the vein”
• Provides access for:
•
•
•
•
Limited fluids
Analgesic pumps
Parenteral antinausea meds
Palliative sedation
(Fast Fact #220 Kamal/Bruera, 2009)
Annie 1
Annie, an 80-year-old lady, was diagnosed with
Alzheimer’s dementia 4 years ago. She now
needs one person assist to get to the bathroom
and is dependent for other ADLs. She has lost
10 # over the past 2 months. She still
recognizes some family but says only one or
two words at a time. She has an active seizure
disorder, requiring daily meds. She is admitted
to the hospital with pneumonia. A swallowing
study shows dysphagia with intermittent
aspiration.
Annie 2
• Annie responds to treatment for her
pneumonia but now her daughter asks
you about options to treat her dysphagia.
• What do you say?
Annie 3
• Annie’s family chooses a PEG tube to
make sure she can get her AEDs, and
they decide to use it for feeding as well.
• One month later she is back in the
hospital with aspiration pneumonia, and
her daughter asks for a family meeting to
reconsider the tube feeding.
• What do you say now?
Annie 4
• Annie goes home with hospice care and
hand feeding. She still chokes at times
but initially takes enough orally to remain
hydrated.
• Two weeks later her hospice nurse asks
for help with her overwhelming oral
secretions.
• What do you order?
Annie 5
• The glycopyrrolate through the PEG tube
works well, but a few days later Annie
stops swallowing completely.
• You are asked to have one more family
meeting.
• What do you say?
Betty 1
Betty B has Stage IV breast cancer
metastatic to bone. Her pain is 10/10 despite
long- and short-acting oral morphine. Her
veins are horrendous after surviving several
bouts of chemotherapy. She enters the
hospital for pain control and is planning to
go home with hospice care. She is
moderately dehydrated with severe oral
thrush. What can you offer her?
Betty 2
• Hypodermoclysis provides:
• Hydration
• Parenteral pain medication
• After the above measures are instituted
and Betty’s thrush is treated she is more
comfortable. She goes home with
hospice.
Summary 1
• Oral intake declines as a natural part of
dying.
• Persons without oral or IV hydration
usually die peacefully in 6-8 days.
• IV fluids at the end of life can increase
edema, congestion, and discomfort.
Summary 2
• Tube feeding in severely demented
patients does not decrease morbidity nor
mortality.
• For rattling, glycopyrrolate has the
advantage of not having brain effects.
• Hypodermoclysis can provide both
medication and limited hydration to
patients who cannot swallow.