Nutrition and Hydration

Purpose: Review of resident’s needs and comfort or distress related to nutrition and hydration during the final stages of life and review of regulatory guidance on the use of parenteral and enteral feeding.

Objectives

• Understand that nutrition and hydration goals are based on the needs and wishes of each resident/surrogate.

• Recognize the IDT’s responsibilities to help the resident meet all nutrition and hydration needs.

• Know that although food and hydration usually provide comfort and nourishment, in the end stages of life they may cause distress.

Objectives, cont.

• Maintain regulatory compliance with nutrition, hydration and artificial feedings.

• Provide families with information and support regarding nutrition and hydration at the end-of-life.

In Accordance with the Comprehensive Assessment and

Plan of Care

World Health Organization (WHO)

Palliative care defined as “active total care of patients whose disease is not responsive to curative treatment…..”

Goal of Palliative Care

WHO

Goal of palliative care is to achieve “the best quality of life for patients and their families.”

“The regulatory requirement for the resident to achieve the highest level of well-being in accordance with the comprehensive plan of care applies to any resident at any time during his or her stay and the LTC facility.”

Appropriate Nutrition and Hydration Goals

“The primary goal of nutrition and hydration in terminal illness is comfort-improving quality of life by giving the resident maximum enjoyment from eating.”

Appropriate Nutrition and Hydration Goals, cont.

“Another goal is to maintain the resident’s nutritional status or optimize the resident’s intake.”

Goals Difficult to Balance in LTC

IDT Members

• Registered Dietician (RD) • Dietary Manager• Occupational Therapist• Physical Therapist• Charge Nurse• Nurse Assistant• RAI/MDS Coordinator• Pharmacist• Physicians

Inappropriate Nutrition and Hydration Goals

“Tradition goals of a balanced diet and achieving an ideal weight are not realistic or appropriate in end stages of life.”

“Traditional diets that restrict salt, cholesterol, or sugar may no longer be appropriate unless the resident prefers the restriction.”

Comfort versus Distress

• Primary goal always comfort!• Highly individualized• “One size fits all” care planning won’t work• End-of-life to “imminent death” – broad

category• What brings comfort in early stage will

bring distress is later stage.• Staff must be aware of ongoing changes

Comfort versus Distress, cont.

• Offer frequent, smaller feedings.• Cravings change from one moment to the

next.• Never make the resident feel guilty for not

trying to eat.• Forcing food and fluid can cause distress.• Intake during the dying process does not

improve the quality of life.

Comfort versus Distress, cont.

• Dehydration prevents distressing symptoms

• Dehydration is not painful

• Dehydration described as euphoria as endorphins are released

• Dry mouth and membranes will cause distress if not managed.

Nutrition and Hydration Regulatory Guidelines

State Operations Manual, Appendix PInvestigative Protocol

“If a resident is at end of life stage and has an advance directive, according to state law, or the resident has reached an end of life stage in which minimal amounts of nutrients [fluids] are being consumed or intake has ceased, and all appropriate efforts have been made to encourage and provide intake, then weight loss [dehydration] may be an expected outcome….”

Nutrition and HydrationRegulatory Guidelines, cont.

Directions to surveyors, cont.

“Conduct observations to verify that palliative interventions, as described in the plan of care, are being implemented and revised as necessary, to meet the needs/choices of the resident in order to maintain the resident’s comfort and quality of life.”

Medications

First, all medications should be reviewed to ensure that they are necessary given the resident’s changing condition. Then medications that might improve appetite can be considered.

Medications to Improve Appetite

• Steroids

• Megace (megestrol)

• Periactin (cyproheptadine)

• Remeron (mirtazapine)

• Marinol (dronabinol)

• Pain control medications

Parenteral and Enteral Feedings

Benefits and Burdens• Discuss with resident and family• Specialized roll in head and neck or

esophageal cancers• High incidence of aspiration, self-removal,

and restraints• Symptoms such as nausea, rattling

pulmonary secretions, and diarrhea

Parenteral and Enteral Feedings, cont.

• GI system fails to absorb food at end of life resulting in weight loss, abnormal labs, and pressure sore development.

• Fluid overload can occur with artificial fluids, which can hasten death and aggravate the dying process.

• In case of doubt, a short trial of rehydration may be appropriate to flush drug by-products in cases of mental confusion.

Regulatory Compliance in the Use of Feeding Tubes

42 CFR 483.25. (g) F321

Nasogastric Tubes

“Based on the comprehensive assessment of a resident, the facility must ensure that a resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident’s clinical condition demonstrates that use of a naso-gastric tube was unavoidable.”

Regulatory Compliance in the Use of Feeding Tubes

Resident Assessment Protocal (RAP)Feeding Tubes

“…..informed consent is essential before inserting a feeding tube. Potential advantages, disadvantages, and potential complications need to be discussed. Resident preference is normally given the great weight in decisions regarding tube feeding…. technical means of providing fluids and nutrition can represent extraordinary rather than ordinary means of prolonging life.”

Family Attitudes

• Eating and drinking as symbolic gesture of giving love

• Food as a celebration and social event • Refusing foods may be perceived as

refusing love• Help family refocus energy by providing

nourishment for the mind and spirit• Help family find meaningful ways to visit

Family Attitudes, cont.

Ways to visit meaningfully:• Apply lotion to hands and feet• Give a back massage• Apply moisturizer to the lips• Remember earlier times and happenings• Play audio tapes of nature sounds and music• Talk about past life memories/experiences• Sit in silence and share the time

When Staff Become Family

• Be aware of one another’s emotional attachment to dying residents

• Staff become surrogate family• Nurture caring relationships, allow for grief• Grief counseling services for staff and families• Manage all aspects of death and grieving in a

healthy manner.• Everyone needs good memories and support as they

deal with difficult situations of living and helping others during their time of dying.