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DMFeature

Dietary Manager12

&

NutritPalliative CA Hospice Dietiti

by |

Donna Gavin,

EveninHospice

Food

isLife.

FoodisLove.

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comfort care, affirms life and neitherhastens or postpones death.

Curative care, on the other hand, fo-cuses on quantity of life, attemptingto prolong lifeeven if it is painful or

includes interventions that may nothave successful outcomes.

Hospice strives for the best possiblequality of life for the patient andfam-ily. Both patients and families partici-pate in the plan of care, with the pa-tients preferences and outlook on lifeand death of paramount importance.

Pain and symptom management topromote comfort care are the corner-stones of hospice. Pain is relative toeach individual, and patients shouldnot feel they have to be stoic or suf-fer as they approach death. Illnesseslike cancer can be painful in the laststages; 70 percent to 90 percent ofpatients with advanced cancer reportpain. Uncontrolled pain can lead todepression, lack of sleep, and a feel-ing of hopelessness.

There are barriers to appropriate painmanagement. If the patient is dement-ed or aphasic, he or she isnt able to

effectively describe the pain. Somepeople may fear that opioid medica-tions such as morphine can lead toaddiction. And pain managementdoes not depend solely on medica-tion; adjunct therapies include sup-portive talk, singing, prayer, gentletouch or massage, and music. Distrac-tions such as reading, humor, and TValso may help.

Who Receives Hospice Care?

A patient who has been diagnosedwith a terminal illness, who is likelyto die in six months or less, and whomeets certain criteria is eligible forthe Medicare hospice benefit. Medi-cal conditions and their criteria mayinclude:

ALS or Lou Gehrigs disease: criticalnutrition impairment, rapid diseaseprogression in the past six months.

Food is life. Food is love. If youare reading DIETARY MANAG-ER, you are probably a health-

care professional who has chosenthis field because of an interest in

food and nutrition.

Food not only provides nourishment,but is regarded as an expression ofnurturing and concern. Food is a vi-tal part of our daily existence, withcultural, ethnic, and religious associa-tions the world over. We commemo-rate special occasions and holidayseven funeralswith food. When aperson shows a decrease in appetite,it is upsetting to all concerned.

A terminally ill patient may not wantto eat because of nausea, vomiting,diarrhea, depression, constipation,or mouth sores. But as the patientsappetite decreases and he or sheloses weight, there arises a conflict

within the strong symbolic connec-tion between food, survival, and love.

A patients refusal to eat may lead toanger, frustration, and sadness on thefamilys part. That is one reason whyhospice provides a team approach to

palliative nutrition care.I am a resource dietitian for VITASInnovative Hospice Careof Chicago-land Northwest, which serves approx-imately 400 terminally ill patients outof its Lombard, IL, office. VITAS hasseven patient care teams in Lombard,and I attend as many of the weeklyteam meetings as I can, because it isat team meetings where I learn aboutnew patients and discuss with theteam how current patients are do-

ing. Each team has a manager, doctor,chaplain, social worker, and a nursingstaff of RNs and CNAs. We also have

volunteers, music therapists, massagetherapists, and a resource dietitian.

What is the Goal of Hospice?

Hospice provides palliative care witha focus on the quality of life and thequality of the dying journey. Dyingis recognized as part of the normalprocess of living. Palliativecare, or

13JANUARY 2007

onrePerspective

N, CDM, CFPP

(Continued on page 14)

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Dietary Manager14

Cancer that is not likely to respondto chemotherapy to allow survivalpast six months.

Dementia: unable to walk withoutassistance, incontinence, no mean-

ingful verbal communication, andone of the following: hx of aspira-tion pneumonia, UTI, pressureulcer (stage 3 or 4), or the inabilityto sustain adequate food and fluids.

Failure to thrive: extensive assis-tance with activities of daily living(ADLs), a Body Mass Index (BMI)of

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15JANUARY 2007

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7 2 4 . 4 5 2 . 8 7 9 4

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Nausea and vomiting are otherrisks associated with ANH.

What to Expect at the End of Life

There often is a progression in the

decline in terminally ill patients. Thisdecline may take place over severalmonths. The patient may preparefor death by talking about goinghome or giving away possessions.He or she may sleep more, eat less,talk less, and be less interested in sur-roundings. The patients hands mayappear blue or purple and the bodytemperature may drop by a degree ormore. You might notice a change inbreathing patterns, such as a series of

rapid breaths followed by a period ofno breaths, known as Cheyne-Stokesrespiration. Hearing is often the lastsense to go, so be thoughtful aboutwhat you say to and about a seeming-ly unresponsive patient.

The Physiology of Dehydration and

Starvation

When the patient refuses to eat ordrink, families become anxious,

fearing that the patient will starveto death. Food has such a powerfuland positive association with healthand well-being that it is upsetting to

watch a loved one refuse to eat andlose weight.

The literature suggests there is nopain associated with dehydrationand starvation. Research shows thatpeople who stop eating and drink-ing slowly become unconscious over

a few days and then die peacefully.When food and fluids are withheld orwithdrawn, the person will be moreaffected by dehydration.

The minimal discomfort of a drymouth can be taken care of withgood oral hygiene care. Intravenousfluids do not reverse thirst. As a per-son becomes dehydrated, ketonesproduced in the body act as a natu-ral anesthetic, creating euphoria.Ketones also cause a decrease in the

level of consciousness.

I have two wonderful patients whoare thriving with hospice interven-tions. Joes diagnosis is failure to

(Continued on page 16)

It is the dietitians

responsibility to provide a

combination of emotional

support and technical

nutrition advice on how best

to achieve each hospice

patients goal.

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Dietary Manager16

DMFeature (Continued)

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Nutrition

End-of-Life Issues

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thrive; he weighs 94 pounds and hasshortness of breath and a history ofalcohol abuse. The nurse caring for

Joe gave him medication to ease hisbreathing and stimulate his appetite.

I suggested calorically dense foodssuch as cheese, peanut butter, forti-fied shakes made with ice cream,cooked cereal, soups, and mashed po-tatoes made with whole milk, butter,and protein powder. I also suggesteda multi-vitamin and B complex. Joeperked up, and the next time I sawhim he was singing and telling jokes.By September he had gained ninepounds, and celebrated his 90thbirthday in style. I saw Joe again just

before Thanksgiving. He weighed 113poundsa weight gain of 19 poundssince he came into hospice. I told himhe was getting fat and sassy, and helaughed.

Ellen is a 93-year-old patient withdementia, failure to thrive, and skin

breakdown. Last summer her weightwas 77 pounds with an ideal bodyweight of 100 pounds. She was bedbound and living with her son. Sug-gestions I made for Ellen included

small, frequent meals and caloricallydense foods. I wrote a recommenda-tion for an ice cream sundae everynight to be served on her DessertRose china with a pretty placemat.

Despite the combined efforts of thehospice team, Ellen continued todecline and the team believed Ellen

would do better in a nursing home.Her son was hesitant to do this,prompting a meeting of the hospiceteam, the son, and his pastor. The son

was quite emotional and expressedguilt about placing his mother in anursing home, but agreed to try.

Two months later I visited Ellen inher nursing home and was amazed tofind her dressed, sitting in the diningroom and feeding herself. She told me

the food was good; I was delighted todiscover that she weighed 88 pounds.I saw her a month later; she weighed95.6 pounds and reported, The foodis still good!

Ellen was thriving, and that made myday. Even in hospice, food is life, foodis love.

Donna Gavin, RD, LDN, CDM, CFPP is a

consultant dietitian. She teaches food, nu-

trition and cultural diversity at Harper

College in Palatine, IL, in addition to her

work with VITAS patients.

References:

Arcement, P. End-of-Life Issues & PalliativeCare. Dietary Managers Association MasterTrack Series.

Kinzbrunner, B. 20 Common Problems forEnd-of-Life Care. 2002.

Rapaport, D. Options for Quality PalliativeCare at the End of Life.