Dietitian, Annica Rust, clarifies the role of nutrition during palliative care in advanced cancer patients.
COVID-19 delayed cancer-related services by up to 50% across the world. This has led to a substantial delay in cancer diagnosis, which has subsequently led to an increased need for palliative care. An aging population and an increase in non-communicable diseases (diabetes, cancer, cardiovascular disease and chronic lung illnesses) further confronts the world with the need for palliative care.¹
What is palliative care?
Palliative care is an approach to improve the quality of life of the cancer patient and their family when curative care is no longer considered by the patient and medical team.2,3 Palliative care will also ensure that physical symptoms are relieved, to alleviate isolation, lower anxiety, manage the fear associated with advanced cancer and to assist the patient with being independent for as long as possible.3
The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends offering and implementing nutritional interventions in advanced cancer patients only after discussing the prognosis of the cancer and the expected quality of life and survival as well as the burden associated with nutritional care.⁴
The key role of nutritional care
1. Nutritional screening and assessment in advanced cancer:
it’s recommended to routinely screen all advanced cancer patients for inadequate intake, weight loss, low body mass index (BMI). If at risk, to further investigate for both treatable nutrition related symptoms.⁴
2. Management of nutrition related symptoms such as:
loss of appetite, constipation, dry mouth, mouth sores, poor mouth care, changes in taste and smell, difficulty swallowing and early satiety which is associated with advanced disease.³
3. Feeding should be initiated as tolerated or desired by the patient.
The pleasurable and preferences of eating should be encouraged, without creating a concern about quantity, nutrient content, or energy or protein requirements.3 Hunger in a dying patient is rare therefore feeding should only provide comfort..4
4. Artificial feeding and hydration (ANH)
Enteral (artificial liquid feed to be delivered directly into the gut through a tube) and parenteral (artificial liquid feed to be delivered into the bloodstream intravenously) nutrition are called artificial nutrition and hydration.⁴
Expected survival rate is important to bear in mind when considering artificial feeding and hydration:4
• If the expected survival is several months or years, nutritional care will be more focussed on adequate energy and protein intake to lower metabolic disturbances and to improve quality of life. In this group, artificial nutrition may be initiated if oral intake isn’t sufficient. Risks associated with ANH should always be discussed with the patient.
• If, however, the expected survival is only a few to several weeks, intervention will focus on psychosocial support in combination with non-invasive strategies to manage nutrition related side effects.
• In dying patients who only have hours or days to live, ANH isn’t recommended and unlikely to be beneficial for the patient. Artificial hydration shouldn’t be used for thirst palliation or dry mouth, but rather oral care.
The advanced directives (living will) of the patient will always be respected by a dietitian and the entire medical team. This will also be used as a guide for the medical nutrition therapy, which includes ANH.4
Nutritional care by a dietitian should always be supported by a multi-disciplinary team, which includes: an oncologist, social worker, counsellor, psychologist, speech therapist and occupational therapist, who all provide numerous competencies to improve the patient’s quality of life.
- World Health Organisation (WHO). Statement – Cancer services disrupted by up to 50% in all countries reporting: a deadly impact of COVID
- World Health Organisation (WHO). Palliative care.
- Mahan, L.K. & Raymond, J.L. (eds).2017. Krause’s food and the nutrition care process. 14th ed. St Louis. MO: Elsevier Saunders.
- Druml, C., Ballmer, P.E., Druml, W., Oehmichen, F.M., Shenkin, A., Singer, P., Soeters, P., Weiman, A. & Bischoff, S.C. 2016. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition, 1(1):1-12.
For more info on palliative care and bereavement support please visit The Hospice Palliative Care Association (HPCA)
MEET THE EXPERT – Annica Rust
Annica Rust is a registered dietitian practicing at the Breast Care Unit at Netcare Milpark Hospital, as well as in Bryanston. She assists with medical nutritional therapy for cancer prevention, treatment, survivorship and palliation. She gives individualised nutritional care to prevent or reverse nutrient deficiencies, nutrition-related side effects and malnutrition to maximise quality of life.
Header image by Adocbe Stock