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A PPT about the challenges of anorexia and cachexia at end of life

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Food the four letter word in end of life care" A PPT presentation to help the health care team understand and explain the challenge of anorexia and cachexia. Based on current research. Teaching learning tool.

Text of A PPT about the challenges of anorexia and cachexia at end of life

  • 1. Food - The four letter word in end of life care Prince Edward Island Palliative Care Conference June 13 2014 Katherine Murray BSN MA CHPCN(C) Joshua Shadd MD CCFP Assistant Professor Centre for Studies in Family Medicine

2. The blessings of team! Dr Joshua Shadd Kath Murray 3. Food can cause conflict and frustration for family, staff and for the dying person 4. Outline Introduction, the challenge Simple truths of nutrition The research to support it Ideas for talking with families CACS = Cancer Anorexia Cachexia Syndrome Though some research refers to cancer, the mechanism is similar in other progressive illnesses. 5. Simple Profound truths of nutrition What a patient can eat and drink will become less. Eventually both eating and drinking will become zero. Stopping eating and drinking is natural to the dying process. Dr Michael Downing 6. What is nutritionally right at one stage may be very wrong at another. Aggressive nutritional therapy in advanced disease often contributes to difficulty in symptom control. Food can cause more discomfort than pleasure. Simple Profound truths of nutrition Dr Michael Downing 7. Simple Profound truths of nutrition Dr Michael Downing What one likes is more important than what is right or of value. What works is not necessarily what one likes or what is right. The atmosphere around eating is more important that what is ingested. 8. Letter.. Thank-you so very much.. Since early May 2011 I have been watching my 97 year old mother-in-law slowly starving in a long-term care. When I attempted to ask questions as to why she was not eating, I was treated as if I was asking questions I had no business to ask. I even asked the Director of Care if there was some avenue or some type of Dementia which at some point dictates to the affected person "Thou Shall Not Eat!". 9. Continued The answer she gave me was "Certainly NOT!" That was in a meeting a week ago yesterday. Since then I have been doing my own research on- line and have discovered that indeed as dementia progresses, the brain forgets the importance of food, can't recognize food, forgets how to chew, forgets how to swallow. Then I read your article and have some further info to help me understand what is going on. What a shame that no one on staff could sit down with us to educate us on how common this is near the end of life in a person with dementia. 10. Continued My nursing experience was in acute care so how would I have known this element of dementia?................ I appreciate the Care magazine and always learn something. Thanks. MC - Retired LPN 11. Tom Tom is an 84 year old retired Coast Guard officer. He was admitted to the lodge six months ago with advancing vascular dementia. His wife Phyllis visits daily. She arrives mid morning, participates in activities with him, and helps him with his lunch. They have one child a daughter, Marianne. 12. Tom For the past month Tom has been less interested in activities, and has not been eating well. He seems more tired, has lost weight, and has a persistent cough. Phyllis tries encourages him to eat, and is disappointed when he does not eat. She is worried that when she is not there, that staff do not encourage him to eat as well as she can. Marianne the daughter is worried that he is loosing weight. 13. Tom Dad will never complain, but Im really worried about his appetite. Every day Mom brings him something to eat, and helps him with his lunch. When she is not here, he does not eat well. He is loosing weight. He was never a big man, but now hes getting skinnier by the day! Isnt there something we can do about this? 14. Anorexia Anorexia is the loss of appetite, the decreased interest in food and eating. (Todays discussion is concerning anorexia at end of life only!) 15. Cachexia Involuntary weight loss (>5% from baseline) with loss of muscle > fat. Common in advanced cancer and some other severe, progressive illnesses (e.g. COPD, CHF, AIDS) 16. Decreased Intake Why? Uncontrolled symptoms (pain, dyspnea, nausea) Fatigue Dry and/or sore mouth Difficulty/pain with swallowing Aversion to food odors/tastes S/E of meds - N/V, Constipation Psychological factors: depression, anxiety, stress Cognitive impairment Cancer Anorexia Cachexia Syndrome (CACS) 17. Why wont he eat? 18. It really IS all about cytokines. 19. USES OF CACS Deconditioning 20. Nutrient Intake Systemic Inflammation Systemic Inflammation & Appetite Neural and hormonal signaling between the brain and GI tract controlling appetite and gastrointestinal function IL-1 IL-6 TNF- 21. Why wont he eat? Translation Systemic inflammation causes a variety of different problems which tend to reduce peoples food intake. The bodys reaction to the presence of tumor can directly reduce ones appetite, Dementia, and disease progression, (or cancer and cancer treatments) also have many other effects that indirectly impact food intake as well 22. Why is he losing weight? 23. Nutrient Intake Nutrient ExpenditureMetabolic rate and processes Systemic Inflammation Tumor-produced factors Appetite & gastrointestinal motility cortisol muscle glucose uptake acute phase protein synthesis muscle protein synthesis proteolysis peripheral lipolysis Weight Balance = Intake Expenditure Inefficient energy use Increased breakdown of protein & fat Decreased making of protein Proteolysis inducing factor Lipid mobilizing factor 24. Then why is he losing weight? Translation Inflammation produces changes which accelerate muscle breakdown, and impair muscle rebuilding. This becomes a vicious cycle (less muscle less muscle-building hormone less muscle) On top of that, muscle does not use its energy resources efficiently 25. Are anorexia and cachexia always linked? Does one cause the other? 26. GI Symptom Correlates of Cancer Anorexia Yavuzsen, Supp Care Cancer, 2009 Nausea Constipation Vomiting Belching Abdominal pain Smell changes Bloating Food aversions Indigestion Hiccups Abn. diurnal variations Taste changes Weight loss Early satiety Are anorexia and cachexia linked? 79% 27. Are anorexia and cachexia always linked? Does one cause the other? Translation They usually occur together. They are really part of the same process. Decreased intake and increase spending of energy. However, one is not necessarily directly related to the other. 28. Is he starving? 29. The Physiology of CACS vs. Nutritional Deficiency Starvation Cancer ACS Metabolic efficiency Get more km per liter Get less km per liter Muscle breakdown Fat breakdown 30. So is he starving? Translation Cachexia is different than starvation. In starvation, the body seeks to conserve energy and nutrients. In cachexia, the body spends them even faster than usual. 31. Would Ensure or a feeding tube or an IV with food in it help? 32. Supplemental Nutrition Doesnt Help Among patients undergoing non-surgical cancer treatments: Parenteral nutrition - net harm Voluntary supplements - no effect on mortality Does supplemental nutrition affect clinical outcome? A Systematic Review Koretz, Am J Gastroenterology, 2007 In summary, little evidence was found for benefits .in terminally ill cancer patients Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: A Review Dy, Am J Hospice Palliative Med, 2006 33. Would Ensure, feeding tube or IV with food help? Translation Unfortunately, not much. Supplemental artificial nutrition (e.g. feeding tube) causes at least as much harm as good. 34. Does she need artificial hydration? Parenteral Hydration in Patients With Advanced Cancer: A Multicenter, Double-Blind, Placebo-Controlled Randomized Trial Hydration at 1 L per day did not improve symptoms, quality of life, or survival compared with placebo. 35. Article Reference: Parenteral Hydration in Patients With Advanced Cancer: A Multicenter, Double-Blind, Placebo- Controlled Randomized Trial. Eduardo Bruera et al. JCO Jan 1, 2013:111-118; 36. Would medication help him gain weight? 37. Pharmacotherapy for CACS Agent Appetite Lean Body Mass Notes Megestrol acetate strongest evidence Steroids benefit appears to be short-term (weeks) Cannabinoids not well tolerated by many patients NSAIDs ? mixed results in clinical trials 38. Would medication help him gain weight? Translation Cachexia is caused by a combination of many things therefore no single treatment will fix all the causes. Combining multiple medications may help, but we dont know what would be most safe and effective. Megestrol and a steroid may increase his appetite and energy for the short term, but wont increase his muscles or strength. 39. Does this mean that he will die sooner? 40. Does this mean that he will die sooner? People who have anorexia or cachexia or both have poorer survival than those who have neither. Lasheen, Supp Care Cancer, 2010 41. Does this mean that he will die sooner? Translation Both anorexia and cachexia are bad news. Whether he has one or both symptoms makes little difference. The survival appears to be about the same. If he had a good appetite and no weight loss, then he might live a few months longer. it is less about what we do, and more about what is happening in the body. 42. Is he dying because hes not eating? Anorexia Cachexia is a poor prognostic factor, and may contribute to the mechanism of death, but is not a cause of death. 43. Is he dying because hes not eating? Translation No, he is not eating because he is dying. 44. Putting this in context. Nourishment across the life span 45. Setting the stage Appropriate nourishment across the life span Lets play: Eating at the family reunion. 46. Lets mix the food up. And give people food that they do not normally eat or like to eat. What happens? 47. Can we feed you this fruit and custard? Why? What is the problem? 48. How do you like this food? How about if we gave it to you at every meal? 49. How does this food look for you? Would you like it for dinner? Would you eat it if we really really really wanted you to? How would you feel after? 50. Hey kids, how about some Ensure and mouth care to keep those teeth all shiny? 51. We have some good food for you! How will you be feeling in a few hours? This is our experience of hunger! 52. Come on Mom, just a little more 53. Come on dad, just take a sip! 54. Conclusion Our need for nourishment changes throughout our life It also changes when we are sick ..How might this exercise help you to discuss this topic with family members? 55. Other ways of languaging this? 56. Dr Brueras analogy Tell your patient that her stomach is on strike! 57. Dont fire the caregiver! Change the job description! Other ways to nurture, to be with, to witness 58. Basket of comfort measures 59. Dialogue and discussion 60. Simple Profound truths of nutrition (Dr Michael Downing) 61. Food for Thought What a patient can eat and drink now will become less. Eventually both eating and drinking will become zero. Stopping eating and drinking is natural to the dying process. What is nutritionally right at one stage may be very wrong at another. Aggressive nutritional therapy in advanced disease often contributes to difficulty in symptom control. 62. Food for Thought continued Food can cause more discomfort than pleasure What one likes is more important than what is right or of value. What works is not necessarily what one likes or what is right. The atmosphere around eating is more important than what is ingested. 63. References 1. Acreman S, 2009, Nutrition in palliative pare, British Journal of Community Nursing, Oct; 14 (10): 427-8, 430-1. 2. Argiles JM et al, 2009, The role of cytokines in cancer cachexia, Current Opinion in Supportive and Palliative Care, 3(4): 263-268. 3. Bruera, E. et al., 2013, Parenteral Hydration in Patients With Advanced Cancer: A Multicenter, Double-Blind, Placebo-Controlled Randomized Trial. Journal of Clinical Oncology, Jan 1, 2013:111-118; 4. Cimino JE, 2003, The role of nutrition in hospice and palliative care of the cancer patient. Topics in Clinical Nutrition, 18(3): 154-61. 5. Morley J, Thomas D, Wilson M, 2006, Cachexia: pathophysiology and clinical relevance, American Journal of Clinical Nutrition, 83(4): 735-743. 6. Murphy KT, Lynch GS, 2009, Update on emerging drugs for cancer cachexia. Expert Opinion on Emerging Drugs. 14(4): 619-632. 7. Poehlman E, Dvorak R, 2000, Energy expenditure, energy intake, and weight loss in Alzheimer disease. American Journal of Clinical Nutrition, 71(2): 650s-655s. 8. Reid J et al, 2008, The experience of cancer cachexia: A qualitative study of advanced cancer patients and their family members. International Journal of Nursing Studies, 46: 606-616. 9. Stepp L, Pakiz T, 2001, Anorexia and cachexia in advanced cancer. Nursing Clinics of North America, 36(4): 735-744. 10. Tisdale MJ, 2009, Mechanisms of cancer cachexia. Physiological Reviews, 89: 381-410. 64. The American Journal of Gastroenterology (2007) 102, 412429; Does Enteral Nutrition Affect Clinical Outcome? A Systematic Review of the Randomized Trials Ronald L Koretz MD1, Alison Avenell MD, MRCP, FRCPath, MB, BS, MSc2, Timothy O Lipman MD3, Carol L Braunschweig PhD, RD4 and Anne C Milne MSc, SRD5 Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: A Review of the Literature AM J HOSP PALLIAT CARE October 2006 vol. 23 no. 5 369-377 Sydney Morss Dy, MD, MSc 65. Kath Murray Life and Death Matters [email protected] http://lifeanddeathmatters.ca Contact Information Dr Joshua Shadd Assistant Professor Centre for Studies in Family Medicine UWO Department of Family Medicine [email protected]