Understanding and meeting patients’ nutrition and hydration needs and wishes is a key aspect of palliative care.

For palliative patients in endof- life care, does nutrition still play a part in their therapy? The answer from Dr Zhuang Qingyuan, Consultant, Division of Supportive and Palliative Care, National Cancer Centre Singapore (NCCS), is a resounding “yes”.

“Nutrition is an important part of palliative care,” Dr Zhuang stressed. He explained that it is essential to have a carefully considered nutrition plan and communicate it to patients and their family members with empathy so that they understand the goals of the plan and know what to expect.

Nutrition is an important and emotive issue because it is not just about calories. This is because eating and drinking are often social activities and thus factors in maintaining familial bonds and a sense of normalcy. For some people, food is their nonverbal way to express love and care; for others, many dishes and drinks hold cherished memories and special meaning.

“We often encounter family members who are concerned whether a loved one in palliative care would be hungry or thirsty,” said Dr Zhuang.

Defining end of life

“End of life is commonly referred to as the last year of life. It’s important to bear in mind that a prognosis is actuarial and not definite. Hence, even in the last year of life, treatments do continue with the intent to prolong life, if it aligns with the patient’s and family’s goals,” Dr Zhuang said.

Nutrition and hydration at this stage of life are considered medical interventions to prevent or treat, for example, malnutrition and dehydration. Nutrition recommendations are made after thorough assessment by the medical team. These recommendations should be based on the patient’s wishes and therapy goals, and also what is realistically achievable and medically feasible (see below).

Nutritional needs change A decrease in appetite and thirst — and thus body weight — is natural and to be expected when a patient reaches end of life; it is a sign of the body slowing down. The patient’s alertness fades as metabolism slows down and nutrition needs diminish. This is part of the ongoing disease process and a natural progress of deterioration and demise.

Overzealous artificial nutrition and hydration may result in more harm, especially if the body is unable to tolerate the increase in fluid volume. These may present as swollen peripheries, discomfort from build-up of fluids in the lungs causing breathlessness and increased chest secretions. Delivering tube feeding against wishes may also result in oropharyngeal discomfort and unnecessary bed-restraints.

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A patient’s preference for hydration and nutrition can become complicated and involve considerations of family wishes. Dr Zhuang spoke about one such patient.

“I had a young patient who was terminally ill and had to be on total parenteral nutrition,” he recalled. Total parenteral nutrition is a method of feeding that bypasses the gastrointestinal tract and delivers nutrition through a vein.

The patient confided in Dr Zhuang that he never wanted to be kept alive artificially with nutrition — the patient knew how advanced his cancer was and had accepted that death was imminent. However, the patient could see that his loved ones were struggling to come to terms with his condition and worried about him getting enough to eat and drink.

For the sake of his loved ones, the patient asked to be kept indefinitely on artificial nutrition, which was provided till he passed away in the hospital. “This was a memorable patient because he decided to be on artificial nutrition despite his wishes as an ultimate expression of sacrifice and love for his family,” he shared.

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