Merseyside and Cheshire Palliative Care

Network Audit Group

Nutrition

July 2012

Audit Group

• Catherine Cliff- Specialist Dietician, Wirral Community NHS Trust

• Elaine Hamill- Staff Nurse, Marie Curie Hospice

• Dr Clare Horlick- StR, Marie Curie Hospice

• Margaret Kendall-Consultant Nurse, Warrington Hospital

• Dr Emma Longford- StR, Wirral Hospice St Johns

• Dr Paula Powell- Consultant, St Helens and Knowsley Community Servce

• Dr Elen Royles- FY1, Warrington Hospital

• Alison Young, Consultant Nurse, Royal Liverpool University Hospital

• External Reviewer: Dr P Bliss, Consultant Gastroenterologist, University Hospital Aintree.

Methods

• Initial audit- comprehensive literature review

• Review of current practice- Survey Monkey questionnaire

– Initial survey- January/February 2012

– Secondary survey to explore key themes further- March/April 2012

• Short telephone survey to assess accessibility to services

Audit Presentation

• Literature review

• Results of telephone survey

• Survey Monkey review of current practice

– Initial Questionnaire

– Supplementary Questionnaire

• Standards and Guidelines

• Questions/Comments

Nutrition Audit Literature Review

Malnutrition • Undernutrition effects 5-85% of the elderly population1

• 50% of hospitalised patients1

• Cachexia common in cancer and other types of chronic disease

• Defined as weight loss, anorexia, weakness and asthenia 2

• Also causes reduced performance status, fatigue, metabolic alterations

• Gastric and pancreatic cancers have the highest frequency (83-97%)2

1. Ryan M, Salle A, Favreau AM, Simard G, Dumas JF, Malthiery Y, Berrut G, Ritz P. Oral supplements differing in fat

and carbohydrate content: effect on the appetite and food intake of undernourished elderly patients. Clinical Nutrition,

(2004), 23, 683-689

2. Harle L, Brown T, Laheru D, Dobs A. Omega-3 Fatty Acids for the Treatment of Cancer Cachexia: Issues in designing

Clinical trials of Dietary Supplements. The Journal of Alternative and Complementary Medicine, (2005), 6, 1039-1046

Causes of cachexia

• Not fully understood

• Cytokine excess ( IL-1, IL-6, TNF-α) causes

loss of lipid stores and skeletal muscle protein

• Oncological treatments may lead to

oesophagitis, nausea/vomiting, altered taste

etc leading to decreased oral intake

Cachexia

• Weight loss in all diseases strongly associated with poor outcome

• Poor survival, reduced quality of life, increased risk of infection/complications

• Eating –

– important quality of life issue

– many social activities occur around dining activities. • Providing nutritional support alone does not reverse cachexia

• Weight loss often refractory to therapeutic intervention

• Anorexia precursor of weight loss and should be identified early

Cancer & Cachexia • Calories and cachexia: paucity of clinical trials

• The hallmark of frailty is weight loss thus enhancing

calorie intake is an important quality of life issue in end-

of-life care.

• Caloric supplementation leads to a decrease in

mortality3

• In general calories should be delivered enterally to help

maintain the integrity of the gastrointestinal immune

system.

3. Morley JE. Cancer and cachexia. Current Opinion in Clinical Nutrition and Metabolic Care, (2009, 12), 607-610

Screening & Assessment

Screening vs assessment • Nutritional Screening

- Rapid, simple, general procedure carried out with patients to identify significant risk of nutritional problems. Can be performed by any staff member with the appropriate skills/knowledge

- Nutritional assessment

- - More detailed, specific and in-depth evaluation of a patient’s nutritional state usually performed by an individual with nutrition expertise following identification of risk via screening.4

4. Elia (2003) The ‘MUST’ report. Nutrition screening of Adults: A Multidisciplinary Responsibility. Redditch,

Worcs: British Association of Parenteral and Enteral Nutrition.

Common problems • No agreement on best screening tool5

• Lack of knowledge within the medical

profession6

• Lack of clear guidelines6

• Unclear responsibility7

• Screening tools should be evidence based,

reliable, reproducible, validated and practical8

5. Kondrup J, Allison S P, Elia M, et al (2003) ESPEN guidelines for nutrition screening 2002. Clinical Nutrition 22(4), 415-421

6. Spiro A, Baldwin C, Patterson A, et al (2006) The views and practice of oncologists towards nutrition support in patients receiving chemotherapy. British Journal of Cancer 95(1), 431-434

7. Linsorff-Larsen K, Rasmussen H H, Kondrup J, et al (2007) Management and perception of hospital undernutrition – a positive change among Danish

doctors and nurses. Clinical Nutrition 26(3), 371-378.

8. British Dietetic Association (2009) A framework for screening for malnutrition. Available from

http://members.bda.uk.com/professional_guidance_docs.html

Common tools

• Malnutrition Universal Screening Tool

(MUST)9

• Scored Patient-Generated Subjective Global

Assessment (PG-SGA)10

• The Malnutrition Screening Tool (MST)11,12

9. Todorovic V, Russell C, Stratton R, et al (2003) The ‘MUST’ Explanatory Booklet: A Guide to the ‘Malnutrition Universal Screening Tool’ (MUST) for Adults. BAPAN. Available from www.bapen.org.uk

10. Ottery FD (2000) Patient-Generated Subjective Global Assessment. In: The Clinical Guide to Oncology Nutrition, ed. PD McCallum & CG Polisena, pp 11 – 23. Chicago : The American Dietetic Association.

11. Ferguson M, Capra S, Bauer J, et al (1999a) Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15(6), 458-464.

12. Ferguson M, Bauer J, Gallagher B, et al (1999b) Validation of a malnutrition screening tool for patients receiving radiotherapy. Australasian Radiology 43(3), 325-327

MUST

• Quick and easy to complete

• Applicable to the whole adult population

• Sensitive and reproducible13

• Considers past, present and future

• Minimal training required

• Completed by any trained member of the MDT

• Recommended by NICE & ESPEN

• But…..

• Not specifically validated in cancer or palliative care

• Focus on BMI, could be influenced by disease effect – oedema etc

13. Stratton R J, Hackston A, Longmore D, et al (2004) Malnutrition in hospital outpatients and in-patients: prevalence, cocurrent validity and ease of use of the ‘Malnutriton Universal Screening Tool’ (MUST) for adults. British Journal of Nutrition 92(5), 799-808.

PG-SGA

• Sensitive to subtle changes in short time period (Gupta et al 2005)

• Designed specifically for assessing oncology patients14

• ‘Gold standard’ for cancer patients15

• Also effective in COPD16

• From the patient perspective eliminating bias

• Gives direction for symptom control

• But….

• Excludes patient who are unable to complete

• Lengthy

• Requires high level of training

• Doesn’t consider future

14. Bauer J, Capra S, and Ferguson M (2002) Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. European Journal of Clinical Nutrition 56(8) 779-785 15. Shaw C (2011) Nutrition and Cancer. Blackwell Publishing Ltd. West Sussex. 16. Bauer J, Egan E, Clavarino A (2011) The scored patient-generatedsubjectiveglobalassessment is an effective nutrition assessment tool in subjects with chronic obstructive pulmonary disease. The European e-Journal of Clinical Nutrition and Malnutrition 6(1), 27-30.

MST

• Quick and easy to complete

• Considers past and present changes

• Completed by any trained member of the MDT

• Minimal training required

• Validated with oncology patients

• But…..

• Validated only in radiotherapy and

chemotherapy setting

• Lacks ability to assess symptomatic impact of

disease

• Could be influenced by disease effect –

oedema etc

• Doesn’t consider future

Have you lost weight recently without

trying?

No = 0 Unsure = 2

If yes – how much weight (kg) have

you lost?

1-5kg = 1 6-10kg = 2

11–15kg = 3 15kg or more = 4

Have you been eating poorly because

of a decreased appetite?

No = 0 Yes = 1

Oral Supplementation

Oral supplements- evidence

• Evidence of economic advantage of enteral over parenteral nutrition.17

• Progestional agents, anabolic androgen steroids, dronabinol, growth hormone, insulin have all been used to treat cachexia with inconsistent results.2

• Greatest body of evidence regarding fish oil supplementation

• Specifically eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) & PUFA which may decrease cytokine activity.2

17. Pritchard C, Duffy S, Edington J, Pang F. Enteral Nutrition and Oral Nutrition Supplementation: A review of the Economic Literature. Journal of Parenteral and Enteral Nutrition, (2006), 30, 52-59

2. Harle L, Brown T, Laheru D, Dobs A. Omega-3 Fatty Acids for the Treatment of Cancer Cachexia: Issues in designing Clinical trials of Dietary Supplements. The Journal of Alternative and Complementary Medicine, (2005), 6, 1039-1046

Oral Supplementation- evidence

• Limited trials in patients with malignancy

• Lack of regulation of dietary supplements present

problems for clinical trials.

• A study of practice in a NH found that NH staff do not

consistently provide oral liquid nutritional supplements

where ordered.18

• Compliance low with most patients achieving only half

of the intended daily dose.

• Studies difficult to interpret due to lack of control data.

18. Simmons S, Patel A. Nursing Home Staff Delivery of oral Liquid Nutritional Supplements to Residents at Risk of Unintentional Weight Loss. The American Geriatric Society, (2006), 54, 1372-1376.

Cochrane reviews

Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy

supplementation in elderly people at risk from malnutrition (review). The

Cochrane Library, 2009, issue 2

• Study: Meta-analysis of 62 trials of older people

• Findings: Supplementation produces a small but consistent weight gain in older people (2.2% (95% CI 1.8 to 2.5)).

No benefit to survival

Baldwin C, Weekes CE. Dietary advice with or without oral nutritional

supplements for disease-related malnutrition in adults (review) The

Cochrane Library, 2011, issue 9

• Study: Meta-analysis of 45 studies in adults with disease-related malnutrition

• Findings: Compared dietary advice alone to dietary advice with nutritional supplementation

– Improvements in mid-arm muscle circumference, (mean difference -.89 (95% CI -1.35 to -0.43) triceps skinfold thickness (mean difference -1.22mm 95% CI -2.34 to -0.09) and grip strength (mean difference -1.67kg (95% CI -2.96 to -0.37).

– No evidence of benefit on survival.20

Fish oil preparations & malignancy

• Range of randomised controlled trials with variable results

• Compared to routine care oral nutritional supplementation found to increase dietary intake in patients undergoing radiotherapy (381 kcal/day) 22

• Better weight maintenance (1.3 & 1.7kg (p<0.05), and a significant trend for greater mid-upper arm circumference (9.1 (p<0.06)) 24

• Significant weight gain at week 3 (median 1kg, p 0.024) and 7 weeks (median 2 kg, p 0.033)25

• Improvement in serum albumin prealbumin and transferrin concentrations 25

• Improvement in performance status and appetite at 3 weeks.23

• Good gastrointestinal tolerance (diarrhoea)25

22. Elia M, Van Bokhurst-de Van der Schueren M, Garvey J, Goedhart A, Lundholm K, Nitenberg G, Stratton R. Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: a systematic review. International Journal of Oncology, (2006), 28, 5-23.

23. Barber MD, Ross JA, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. British Journal of Cancer (1999), 81, 80-86.

24. van der Meij B, Langius J, Smit E, Spreeuwenberg M, von Blomberg M, Heijboer A, Paul M, van Leeuwen A. Oral Nutritional Supplements Containing 9n-3) Polyunsaturated Fatty Acids Affect the Nutritional Status of Patients with Stage III Non-Small Cell Lung Cancer during Multimodality Treatment. The Journal of Nutrition, 2010. 140 (10): 1774 - 1780

25. de Luis, Izaola O, Aller E, Cuellar L, Terroba MC, Martin T. A randomised clinical trial with two omega 3 fatty acid enhanced oral supplements

in head and neck ambulatory patients. European Review for Medical and Pharmacological Sciences, (2008), 12, 177-181.

Nutritional supplements- summary

• In elderly malnourished patients oral supplementation reduces hunger1 and improves nutritional assessment scores21

• Often poorly tolerated and compliance is low

• Variable results in trials of non-malignancy

– HIV- Nutritional counselling and oral supplementation both effective.24

– Neurodegenerative conditions-increased body weight/ arm muscle circumference (p<0.05)25

– Renal patients- maintenance of serum albumin (p= .03).26

• In malignancy supplements increase oral intake but no effect on symptoms or survival

• Fish oil preparations may improve weight stabilisation and appetite

• No evidence that supplements were beneficial in reducing complications in peri-operative patients.27

Appetite Stimulants

Appetite Stimulants - Evidence • Reasonable body of quality evidence, including placebo-

controlled RCTs and Systematic Reviews. • The greatest body of evidence is for Megestrol particularly and

also Dexamethasone. • The main outcome measures examined are increased appetite,

weight gain and quality of life indicators. • The majority of studies examine the use of appetite stimulants in

cancer related anorexia-cachexia, although there is also more limited evidence for non-malignant conditions.

• There are also numerous studies examining the efficacy of other more novel medications including Thalidomide, Omega-3-fatty acids and NSAIDs.

• 10 studies examined (1998-2011).

Loprinzi CL, et al. Randomized Comparison of Megestrol Acetate Versus

Dexamethasone Versus Fluoxymestrone for the Treatment of Cancer

Anorexia/Cachexia. Jn Clinical Oncology 1999; 17(10): 3299-3306.28

Study Randomised Controlled Trial Aim To compare and contrast Megestrol 800mg, Dexamethasone 0.75mg qds and Fluoxymestrone 10mg bd for the treatment of cancer anorexia/cachexia. Primary endpoints were weight gain and increased appetite. Toxicity and QOL measures also studied Patient 496 patients, advanced cancer with weight loss Setting Outpatient Oncology Clinic Findings Fluoxymestrone resulted in significantly less appetite enhancement and did not have a favourable toxicity profile Megestrol and Dexamethasone caused a similar degree of appetite enhancement (Appetite inc moderately/considerably M-34%, D-35%) and weight gain (M-2.5kg, D- 2.01kg). (Non-significant trend favouring Megestrol) Dexamethasone had a higher discontinuation rate due to toxicity/pt refusal than megestrol (36% v 25%, P=0.03) Megestrol had a higher rate of DVT compared to Dexamethasone (5% v 1%,P=0.06) Fluoxymestrone inferior choice for appetite stimulation for treating cancer anorexia/cachexia. Megestrol and Dexamethasone have similar appetite stimulating properties but differing toxicity profiles. Therefore individual patient assessment suggested, for shorter term use consider Dexamethasone, for longer term use consider Megestrol due to better side-effect profile.

European Palliative Care Research Collaborative. Clinical practice guidelines on cancer cachexia

in advanced cancer patients: with a focus on refractory cachexia. Updated Feb 2011.29

• Megestrol – evidence from systematic review that Megestrol has a statistically significant benefit for appetite

and weight gain, but not quality of life in the treatment of cancer cachexia.

A range of dosages studied, no significant differences in outcome.

Main adverse effect found vs. placebo was lower limb oedema.

(Level of recommendation – weak positive)

• Steroids – may be beneficial in patients with refractory cachexia for stimulation of appetite and improvement

in QOL, less evidence that steroid treatment results in weight gain.

Effects on appetite/wellbeing appear short-lived (up to 1 month).

Longer duration of treatment may lead to the development of steroid related side-effects and muscle

weakness.

(Level of recommendation – strong positive)

Insufficient evidence to recommend treatment of cachexia with Thalidomide, NSAIDS, Prokinetics,

Cannabinoids, and Omega-3-fatty acids, including eicopentaenoic acid (EPA).

Appetite Stimulants in Palliative Care

• There is statistically significant evidence that Megestrol improves appetite and weight gain in

patients with cancer30.

• There is also evidence that Megestrol increases body weight in non-malignant cachexia

(COPD/AIDS)31,32.

• A wide range of Megestrol doses have been studied – 160mg-800mg.Although there is a trend

particularly amongst oncology patients for greater weight gain at higher doses, this is not

statistically significant32.

• There seems to be minimal adverse effects from Megestrol treatment (lower limb oedema29, in

some studies increased DVT risk28), although the risk is increased with higher doses.

30. Berenstein G, et al. Megestrol acetate for treatment of anorexia-cachexia syndrome. The Cochrane Database of Systematic Reviews 2005, 2. Art N0: CD004310.

31. Herrejon, et al. Low doses of megestrol acetate increase weight and improve nutrition status in patients with sever chronic obstructive pulmonary disease and weight loss. Med Clin

2011; 137(5): 193-8.

32. Lopez AP, et al. Systematic Review of Megestrol Acetate in the Treatment of Anorexia-Cachexia Syndrome. Jn Pain & Symptom Management 2004; 27(4): 360-369.

29. European Palliative Care Research Collaborative. Clinical practice guidelines on cancer cachexia in advanced cancer patients: with a focus on refractory cachexia. Updated Feb 2011.

28. Loprinzi CL, et al. Randomized Comparison of Megestrol Acetate Versus Dexamethasone Versus Fluoxymestrone for the Treatment of Cancer Anorexia/Cachexia. Jn Clinical

Oncology 1999; 17(10): 3299-3306.

Appetite Stimulants in Palliative Care • Corticosteroids have a beneficial effect on appetite and well being in the treatment of cancer

cachexia. However there is more limited evidence for significant weight gain as a result of

treatment33,34.

• Corticosteroids also have additional beneficial effects on nausea, pain control and symptoms of

fatigue/weakness,

• Most studies seem to show a limited effect of up to 4 weeks33.

• Prolonged use leads to a greater incidence of steroid related side-effects28. Due to their side-

effect profile, steroids are therefore generally recommended as treatment for cachexia for

patients with a short expected survival33.

• There is limited evidence that a combination of appetite stimulants (Progesterone/EPA/L-

carnitine/Thalidomide), is superior to single agent treatment of cancer cachexia, in terms of

weight gain, energy expenditure and fatigue35.

33. Gagnon B, et al. A Review of the Drug Treatment of Cachexia Associated with Cancer. Drugs 1998; 55(5): 675-88.

34. Sarcey, et al. Influence of dexamethasone on appetite and body weight in lung cancer patients. Med Pregl 2006; 61(11-12): 571-5.

28. Loprinzi CL, et al. Randomized Comparison of Megestrol Acetate Versus Dexamethasone Versus Fluoxymestrone for the Treatment of Cancer Anorexia/Cachexia. Jn Clinical

Oncology 1999; 17(10): 3299-3306.

35. Mantovani G, et al. Randomized Phase III Clinical Trial of Five Different Arms of Treatment in 332 Patients with Cancer Cachexia. The Oncologist: Symptom Management and

Supportive Care 2010; 15: 200-11.

Appetite Stimulants - Summary

• Both Megestrol and Dexamethasone have been shown to increase appetite and lead to weight

gain in anorexia-cachexia syndrome (less robust evidence for Dexamethasone) in both

malignant and non-malignant disease.

• Effects on QOL are less conclusive, due to the wide range of tools studied.

• Dexamethasone has more short lived effects (up to 4 weeks) and a greater incidence of side

effects, therefore is recommended for patients with a shorter prognosis (<6 weeks).

Dexamethasone has additional beneficial effects through enhancing wellbeing.

• Megestrol seems to have a non-significant advantage over Dexamethasone in terms of

appetite/weight gain and side-effect profile (although some studies have highlighted problems

with increased risk of VTE/leg oedema).

• Megestrol is recommended for longer-term treatment of anorexia/cachexia.

• There is insufficient evidence to recommend a standard dosage of Megestrol, however both

effects on weight gain and side-effects seem to be dose related.

• There is insufficient evidence to recommend other drugs such as EPA, Thalidomide and

NSAIDS, for treatment of anorexia/cachexia, although there is limited evidence that such drugs

in combination may be beneficial.

Enteral Feeding

Enteral Feeding - Evidence

• Lack of quality evidence

• No RCTs looking at enteral feeding within a palliative care setting

• Mainly expert opinion/review and prospective non-controlled trials, with

limited work within palliative care

• Studies within similar patient groups therefore included e.g. advanced

cancer, advanced dementia

• Topics: impact on QOL, impact on survival, ethical considerations, review of

current practice

• 12 papers examined (1999-2003)

NICE Guidance: Nutrition Support for Adults, Oral Nutrition Support,

Enteral Tube Feeding and Parenteral Nutrition, 2006 36

• HCPs should consider enteral feeding in people who are malnourished or at risk of

malnutrition and have: - Inadequate or unsafe oral intake

- A functional, accessible GI tract

• Choice of type of feeding tube depends on : expected period of feeding, clinical condition

and anatomy.

Nasogastric Tubes

• Generally used for short-term support

• Potentially dangerous in those with an unsafe swallow and those nursed flat/prone

• Risk of misplacement on insertion or later

Nasoduodenal/jejunal

• Can be helpful in patients not tolerating enteral feeding due to gastro-oesophageal reflux or

delayed gastric emptying

Gastrostomy/Jejunostomy

• Used for patients requiring medium/long-term feeding (>4 weeks) or where NG access is difficult

• Risks of reflux and aspiration reduced but not negated

NICE Guidance: Nutrition Support for Adults, Oral Nutrition Support,

Enteral Tube Feeding and Parenteral Nutrition, 2006

Type Complication

Insertion Nasal damage, bleeding, perforation

Post insertion trauma Discomfort, erosions, fistulae, strictures

Displacement Tube ‘falls out’

Reflux Oesophagitis, aspiration

GI intolerance Nausea, bloating, pain, diarrhoea

Metabolic Re-feeding syndrome, hyperglycaemia, fluid overload, electrolyte

disturbance

Monitoring • Pts having enteral feeding should have regular expert review. This should occur every 3-6/12 at least • If a patient is at risk of re-feeding syndrome – necessary lab tests should be undertaken

Stroud M, et al. Guidelines for enteral feeding in adult hospital patients. Gut

2003;52(VII):vii1-vii12.37

Reviewed by BSG/BAPEN

• Guidelines formulated by review of the literature, discussion with dieticians and specialist nutrition nurses with further subsequent review by BSG/BAPEN

Recommendations

• Healthcare professionals should aim to provide adequate nutrition to all pts unless prolongation of life is not in the patients best interest(C)

• Artificial nutrition is needed when oral intake is absent/likely to be absent > 5-7 days (A)

• Enteral feeding should never be started without consideration...of patients best interests (C)

• If patients are taking >50% of estimated nutritional requirements it may be appropriate to delay instigation of enteral feeding(C)

• Decisions on route, content and management of nutrition support are best made by multidisciplinary nutrition teams (A)

• PEG/PEJ should be considered if duration of feeding likely to be >4-6/52(C)

• Close monitoring of electrolytes is essential initially after enteral feeding starts (C)

• Targeted nutritional support – reduces hospital complications, length of stay, mortality and costs.

• NJT – considered if problems with reflux/delayed gastric emptying

Cochrane Review: Medically assisted nutrition for palliative care in

adult patients, 2011 38

Objective

• To determine the effect of medically assisted nutrition on the quality and length of life of palliative care patients

Data collection/analysis

• No RCTs or prospectively controlled trials found

Results

• Langmore 2006 Cochrane Review of EF in MND – looked at 7 trials

• 3/7 trials showed longer survival, 4/7 trials – no difference.

• 3/7 looked at nutritional outcomes and suggested positive advantage for pts with PEGs

• 2/7 looked at QOL – no difference after PEG insertion

• Meier 2001 – US trial, Advanced Dementia – increased consultation vs. usual care. PEG insertion didn’t significantly improve survival.

Conclusions

• Insufficient good quality trials to make any recommendations for practice

• Individual assessment of benefits and harms is needed

• Patients with a good PS and medium/long prognosis (months - years) may benefit

Enteral Feeding in Palliative Care

• Indications for enteral feeding in palliative care commonly include patients who have had radical

oesophageal surgery, upper GI tract obstruction, anorexia and dysphagia39.

• Enteral nutrition initiated for palliative care patients with head and neck cancer can slow down

nutritional deprivation, avoid dehydration and improve QOL40.

• An individual assessment of risk and benefits of initiating enteral feeding is needed41.

• Within the palliative population any complication or discomfort from enteral nutrition should be

considered40, as enteral and particularly PEG feeding has inherent risks

• PEG insertion is associated with significant mortality - 8-22% at 30 days42,43. Certain factors

may increase this risk further within palliative patients – increased age, lower BMI42.

39. Gilbar PJ. A Guide to Enteral Drug Administration in Palliative Care. Jn of Pain and Symptom Management, 1999; 17(3): 197-207

40. Bachmann P, et al. Practice Guideline: Summary version of the Standards, Options and Recommendations for palliative or terminal nutrition in adults with progressive cancer(2001). Br

Jn of Cancer 2003; 89(Supp 1): S107-S110.

41. British Geriatrics Society: Nutritional Advice in Common Clinical Situations. (Revised Aug 2009)

42. Zopf Y, et al. Predictive Factors of Mortality After PEG Insertion: Guidance for Clinical Practice. JPEN 2011; 35(1): 50-55.

43. Janes S, et al. Percutaneous endoscopic gastrostomy: 30 day mortality trends and risk factors. JPGM 2005; 51(1): 23-29.

Enteral Feeding in Palliative Care • Evidence suggests in other similar groups such as those with advanced dementia or MND,

PEG feeding does not improve prognosis, prolong survival, increase QOL, functional status

or nutritional status41,44.

• Timely consideration of feeding is important and generally it is suggested as most

appropriate in those with a medium to long-term prognosis

• Guidelines for those with Progressive Cancer suggest artificial nutrition should only be

considered for those with an expected life expectancy of >3/12, without severe functional

deficit (PS 2 or less)40.

• This is supported by a Swedish study of artificial nutrition in cancer patients enrolled in

palliative home care services, where enteral feeding was usually introduced >4/12 before

death45.

41. British Geriatrics Society: Nutritional Advice in Common Clinical Situations. (Revised Aug 2009) 44. Katzberg HD, et al. Enteral tube feeding in amyotrophic lateral sclerosis/motor neurone disease. Cochrane

Database 2011 Jan 19; (1):CD004030. 40. Bachmann P, et al. Practice Guideline: Summary version of the Standards, Options and Recommendations for

palliative or terminal nutrition in adults with progressive cancer(2001). Br Jn of Cancer 2003; 89(Supp 1): S107-S110.

45. Orrevall Y, et al. The use of artificial nutrition amongst cancer patients enrolled in palliative care home services. Palliative Medicine 2009; 23: 556-564.

Enteral Feeding - Summary

• Evidence mainly drawn from expert opinion • Limited evidence for quality of life or increased survival benefit

when enteral feeding is used in the setting of palliative care • However enteral feeding should be considered for those

patients at risk of malnutrition because of inadequate/unsafe oral intake, who have a functioning GI tract

• Due to risks/burdens of enteral feeding an individual patient assessment of best interests regarding enteral feeding is needed by the MDT with expert dietetic input

• Generally enteral feeding should only be considered for patients with a medium to long-term prognosis (>3/12) who have a good performance status (PS 2 or less)

• Patients maintained on enteral feeding should have regular expert dietetic review (at least every 3-6/12)

Protected Mealtimes

Protected Mealtimes (i)

• NHS/National Patient Safety Agency- Protected Mealtimes review, January 2007.

– Clear benefits associated with Protected Mealtime Initiative (PMI)

– Study at Hull Royal infirmary

• Wards with PMI- 74% patients gained weight

• Wards without PMI- 56% patients lost weight

– Reduced food wastage

– Fewer complaints

– Recommendations:

• All NHS staff are encouraged to implement Protected Mealtimes to improve the safety of their patients at mealtimes

• Healthcare inspectors should include the implementation of Protected Mealtimes as part of their healthcare standards

Protected Mealtimes (ii)

• Council of Europe Resolution Food & Nutrition Care In Hospitals. (2003)

– 10 key characteristics of good nutritional care in hospital,

– ward implementation of a Protected Meal time to provide an environment conducive to the patient enjoying & being able to eat their food.

• The Department of Health, Essence of Care Benchmarks for Food & Drink (2010)

– lists 10 factors of which no 6 is Environment.

'The environment should be conducive to enable individual patients to eat & that they should receive the care & assistance they require with eating & drinking'.

• The Commission for Patient & Public Involvement. In Health Food Watch Report (2006).

– Patients who are uninterrupted & receive appropriate service & support during mealtimes feel happier, more relaxed & eat more.

Protected Mealtimes (iii)

• Protected Mealtime Initiative – introduced in 2004 as part of The Better Hospital Food Programme.

encourages all non urgent ward activity to stop during meal times. During this time patients are able to eat their meal without interruption & nursing staff are able to offer help to those who need it. (National patient Safety Agency 2006).

– has received full support from the Royal College of Nursing

'Busy nurses working in complex environments often struggle to prioritise with so many competing demands. When a whole organisation embraces the importance of Protected Mealtimes, patients benefit'.

(Geraldine Cunningham, Acting Director of the RCN Institute, cited by Hospital Caterers Association. Better Hospital Food 2012).

• National Patient Safety Agency

– identified poor nutrition as a patient safety issue

– believes Protected Mealtimes have the potential to improve patient safety by ensuring 'patients receive the right meal at the right time with the right amount of help'.

References (i)

• 1. Ryan M, Salle A, Favreau AM, Simard G, Dumas JF, Malthiery Y, Berrut G, Ritz P. Oral supplements differing in fat and carbohydrate content: effect on the appetite and food intake of undernourished elderly patients. Clinical Nutrition, (2004), 23, 683-689

• 2. Harle L, Brown T, Laheru D, Dobs A. Omega-3 Fatty Acids for the Treatment of Cancer Cachexia: Issues in designing Clinical trials of Dietary Supplements. The Journal of Alternative and Complementary Medicine, (2005), 6, 1039-1046

• 3. Morley JE. Cancer and cachexia. Current Opinion in Clinical Nutrition and Metabolic Care, (2009, 12), 607-610

• 4. Elia (2003) The ‘MUST’ report. Nutrition screening of Adults: A Multidisciplinary Responsibility. Redditch, Worcs: British Association of Parenteral and Enteral Nutrition.

• 5. Kondrup J, Allison S P, Elia M, et al (2003) ESPEN guidelines for nutrition screening 2002. Clinical Nutrition 22(4), 415-421

• 6. Spiro A, Baldwin C, Patterson A, et al (2006) The views and practice of oncologists towards nutrition support in patients receiving chemotherapy. British Journal of Cancer 95(1), 431-434

• 7. Linsorff-Larsen K, Rasmussen H H, Kondrup J, et al (2007) Management and perception of hospital undernutrition – a positive change among Danish doctors and nurses. Clinical Nutrition 26(3), 371-378

• 8. British Dietetic Association (2009) A framework for screening for malnutrition. Available from http://members.bda.uk.com/professional_guidance_docs.html

• 9. Todorovic V, Russell C, Stratton R, et al (2003) The ‘MUST’ Explanatory Booklet: A Guide to the ‘Malnutrition Universal Screening Tool’ (MUST) for Adults. BAPAN. Available from www.bapen.org.uk

• 10. Ottery FD (2000) Patient-Generated Subjective Global Assessment. In: The Clinical Guide to Oncology Nutrition, ed. PD McCallum & CG Polisena, pp 11 – 23. Chicago : The American Dietetic Association.

• 11. Ferguson M, Capra S, Bauer J, et al (1999a) Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15(6), 458-464.

• 12. Ferguson M, Bauer J, Gallagher B, et al (1999b) Validation of a malnutrition screening tool for patients receiving radiotherapy. Australasian Radiology 43(3), 325-327

• 13. Stratton R J, Hackston A, Longmore D, et al (2004) Malnutrition in hospital outpatients and in-patients: prevalence, cocurrent validity and ease of use of the ‘Malnutriton Universal Screening Tool’ (MUST) for adults. British Journal of Nutrition 92(5), 799-808.

References (ii)

• 14. Bauer J, Capra S, and Ferguson M (2002) Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. European Journal of Clinical Nutrition 56(8) 779-785

• 15. Shaw C (2011) Nutrition and Cancer. Blackwell Publishing Ltd. West Sussex.

• 16. Bauer J, Egan E, Clavarino A (2011) The scored patient-generatedsubjectiveglobalassessment is an effective nutrition assessment tool in subjects with chronic obstructive pulmonary disease. The European e-Journal of Clinical Nutrition and Malnutrition 6(1), 27-30.

• 17. Pritchard C, Duffy S, Edington J, Pang F. Enteral Nutrition and Oral Nutrition Supplementation: A review of the Economic Literature. Journal of Parenteral and Enteral Nutrition, (2006), 30, 52-59

• 18. Simmons S, Patel A. Nursing Home Staff Delivery of oral Liquid Nutritional Supplements to Residents at Risk of Unintentional Weight Loss. The American Geriatric Society, (2006), 54, 1372-1376.

• 19. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition (review). The Cochrane Library, 2009, issue 2

• 20. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults (review) The Cochrane Library, 2011, issue 9

• 21. Arnaud-Battandier F, Malvy D, Jeandel C, Schmitt C, Aussage P, Beaufrere B, Cynober L. Use of oral supplements in malnourished elderly patients living in the community: a pharmaco-economic study. Clinical Nutrition, (2004), 23, 1096-1103

• 22. Elia M, Van Bokhurst-de Van der Schueren M, Garvey J, Goedhart A, Lundholm K, Nitenberg G, Stratton R. Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: a systematic review. International Journal of Oncology, (2006), 28, 5-23.

• 23. Barber MD, Ross JA, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. British Journal of Cancer (1999), 81, 80-86.

• 24. van der Meij B, Langius J, Smit E, Spreeuwenberg M, von Blomberg M, Heijboer A, Paul M, van Leeuwen A. Oral Nutritional Supplements Containing 9n-3) Polyunsaturated Fatty Acids Affect the Nutritional Status of Patients with Stage III Non-Small Cell Lung Cancer during Multimodality Treatment. The Journal of Nutrition, 2010. 140 (10): 1774 - 1780

References (iii)

• 25. de Luis, Izaola O, Aller E, Cuellar L, Terroba MC, Martin T. A randomised clinical trial with two omega 3 fatty acid

enhanced oral supplements in head and neck ambulatory patients. European Review for Medical and Pharmacological

Sciences, (2008), 12, 177-181.

• 26. Scott MK, Shah NA, Vilay AM, Thomas J, Kraus MA, Mueller BA. Effects of peridialytic oral supplements on

nutritional status and quality of life in chronic hemodialysis patients. Journal of Nutrition, (2009), 19(2), 145-52.

• 27. Burden ST, Hill J, Shaffer JL, Campbell M, Todd C. An unblinded randomised controlled trial of preoperative oral

supplements in colorectal cancer patients. Journal of Human Nutrition and Dietetics, (2011), 24, 441-448.

• 28. Loprinzi CL, et al. Randomized Comparison of Megestrol Acetate Versus Dexamethasone Versus Fluoxymestrone for the Treatment of Cancer Anorexia/Cachexia. Jn Clinical Oncology 1999; 17(10): 3299-3306.

• 29. European Palliative Care Research Collaborative. Clinical practice guidelines on cancer cachexia in advanced cancer patients: with a focus on refractory cachexia. Updated Feb 2011.

• 30. Berenstein G, et al. Megestrol acetate for treatment of anorexia-cachexia syndrome. The Cochrane Database of Systematic Reviews 2005, 2. Art N0: CD004310.

• 31. Herrejon, et al. Low doses of megestrol acetate increase weight and improve nutrition status in patients with sever chronic obstructive pulmonary disease and weight loss. Med Clin 2011; 137(5): 193-8.

• 32. Lopez AP, et al. Systematic Review of Megestrol Acetate in the Treatment of Anorexia-Cachexia Syndrome. Jn Pain & Symptom Management 2004; 27(4): 360-369.

• 33. Gagnon B, et al. A Review of the Drug Treatment of Cachexia Associated with Cancer. Drugs 1998; 55(5): 675-88.

• 34. Sarcey, et al. Influence of dexamethasone on appetite and body weight in lung cancer patients. Med Pregl 2006; 61(11-12): 571-5.

• 35. Mantovani G, et al. Randomized Phase III Clinical Trial of Five Different Arms of Treatment in 332 Patients with Cancer Cachexia. The Oncologist: Symptom Management and Supportive Care 2010; 15: 200-11.

References (iv)

• 36. NICE Guidance: Nutrition Support for Adults, Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition, 2006

• 37. Stroud M, et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003; 52(VII):vii1-vii12. Reviewed by BSG/BAPEN.

• 38. Cochrane Review: Medically assisted nutrition for palliative care in adult patients, 2011

• 39. Gilbar PJ. A Guide to Enteral Drug Administration in Palliative Care. Jn of Pain and Symptom Management, 1999; 17(3): 197-207

• 40. Bachmann P, et al. Practice Guideline: Summary version of the Standards, Options and Recommendations for palliative or terminal nutrition in adults with progressive cancer (2001). Br Jn of Cancer 2003; 89(Supp 1): S107-S110.

• 41. British Geriatrics Society: Nutritional Advice in Common Clinical Situations. (Revised Aug 2009).

• 42. Zopf Y, et al. Predictive Factors of Mortality After PEG Insertion: Guidance for Clinical Practice. JPEN 2011; 35(1): 50-55.

• 43. Janes S, et al. Percutaneous endoscopic gastrostomy: 30 day mortality trends and risk factors. JPGM 2005; 51(1): 23-29.

• 44. Katzberg HD, et al. Enteral tube feeding in amyotrophic lateral sclerosis/motor neurone disease. Cochrane Database 2011 Jan 19; (1):CD004030.

• 45. Orrevall Y, et al. The use of artificial nutrition amongst cancer patients enrolled in palliative care home services. Palliative Medicine 2009; 23: 556-564.

• 46. Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment to nutritional counselling in malnourished

HIV-infected patients: randomized controlled trial. Clinical Nutrition, (1999), 18(6), 371-374.

• 47. Trejo A, Boll MC, Alonso E, Ochoa A, Velasquez. Use of oral nutritional supplements in patients with Huntingdon’s

disease. Nutrition, (2005), 839-894.

References (v)

• 48. Mantovani G, Maccio A, Madeddu C, Gramignano G, Serpe R, Massa E, Dessi M, Tanca FM, Sanna E, Deiana L, Panzone F, Contu P, Floris MD. Randomized phase III clinical trial of five different arms of treatment for patients with cancer cachexia: interim results. Nutrition, (2008), 24, 305-313.

• 49. Boehnke Michaud L, Phillips Karpinski J, Jones K, Espirito J. Dietary supplements in patients with cancer: Risks and key concepts, part 1.American Journal of Health-System Pharmacy, 2007 15, 369-81

• 50. Shragge JE, et al. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliative Medicine 2006; 20: 623-9.

• 51. Fabbro ED, et al. Symptom Control in Palliative Care – Part II: Cachexia/Anorexia and Fatigue. Jn Pall Medicine 2006; 9(2): 409-21.

• 52. Buiting HM, et al. Artificial nutrition and hydration for patients with advanced dementia: perspectives from medical practitioners in the Netherlands and Australia. Palliative Medicine 2011; 25(1): 83-91.

• 53. Ersek M. Artificial Nutrition and Hydration. Jn of Hospice and Palliative Nursing 2003; 5(4): 221-228.

Audit Results

A short telephone survey of nutrition services in palliative care in Merseyside and Cheshire

Responses from 7 specialist palliative care inpatient units:

Hospice of the Good Shepherd

Marie Curie Hospice Liverpool

Queenscourt Hospice

St Rocco's Hospice

Willowbrook Hospice

Wirral Hospice St John's

Woodlands Hospice

3 questions asked

1. Do you have a nutritional lead?

2. Do you have any specific educational

information available about nutrition in

palliative care?

3. Do you have a nutrition policy?

Do you have a nutritional lead?

No n=5

Yes n=0

In Process n= 2

Any specific educational information available about

nutrition in palliative care?

No n=5

Yes n=0

Use LocalHospitalDietcianService n=2

Do you have a nutrition policy?

No n=4

Yes n=2

In Process n=1

Results of Survey Monkey Questionnaires

Results

• Survey Monkey review of current practice

– Initial Questionnaire

• February 2012

• 110 responders

– Supplementary Questionnaire-

• March/April 2012

• 61 responders

ICN data (Secondary survey only)

0

5

10

15

20

25

Ain

tree

Halton

Isle

of

Man

Liv

erp

ool

South

port

/Form

by/

West

Lancs

St

Hele

ns &

Know

sle

y

Warr

ingto

n

Weste

rn C

heshire

Wirra

l

Setting (Secondary Survey Only)

42%

29%

29%

Inpatient Specialist Care unit

Acute Hospital

Community

Roles (Secondary Survey Only)

59%

30%

7%2%2%

Doctor

CNS

Staff Nurse

Dietician

Other

Do you routinely discuss diet and/or

nutrition with your patients?

90%

10%

Yes

No

Do you use any nutritional screening/assessment

tools in your practice or place of work?

If Yes which: Aintree Nutritional screening tool

MUST

Hospice nutritional tool

Palliative care dietician own form

Teams dietician nutritional assessment for palliative care

Trust own tool

36%

64%

Yes

No

How effective is this assessment tool?

• ‘Guides management, but often screening during Hx

and Exam guides my practice’

• ‘MUST - validated tool and v effective’

• ‘Often easy to establish patients "score" without using

the tool but by visual assessment’

• ‘Fairly effective’

• ‘Very effective’

• ‘Not that effective, tend to use clinical judgement’

Within your multidisciplinary team do you have access to a

dietician or other specialist nutritional advice?

Yes

65%

No

30%

Don't Know

5%

What do you do if nutritional advice is required?

● Refer to community dietician

● Contact GP

● Refer to hospital

If you identify a patient with compromised nutritional status, what

action or actions do you take? (Tick all applicable)

Other: Refer to doctor, liaise with catering, prescribe steroids

0

10

20

30

40

50

60

70

80

90

1

No action

Food charts

Assessment tool

Offer referral to dietician

Basic verbal advice

Basic written advice

Prescribe supplements

Prescribe appetite stimulant

Review symptoms

Seek advice from specialist

Other

Where you identify a patient you feel may benefit from artificial

nutritional support, do you have access to a care or referral

pathway?

43%

25%

32%

Yes

No

Don’t Know

Do you have access to written information for patients regarding

nutrition?

56%34%

10%

Yes

No

Don’t Know

Is there a protected mealtime in your place

of work?

100

58

0

42

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hospital Hospice

No

YesIs this adhered to?:

Not adhered to

Generally yes

Strictly

No need to protect mealtimes- ‘draconian measures’

Medical staff do not adhere to it

Do you prescribe or advise prescription of oral nutritional

supplements in palliative care patients?

64%

36%

Yes

No

What proportion of patients that you see are already prescribed oral

nutritional supplements?

42.6 43.6

13.8

0

0

5

10

15

20

25

30

35

40

45

50

0-25 26-50 51-75 76-100

Which oral nutritional supplements do you

prescribe or advise prescription of?

0

10

20

30

40

50

60

70

1

Supplement

Fre

qu

ency

Ensure Plus M ilkshake Style

Ensure Plus Fibre

Ensure Plus Savoury

Ensure plus Juice

Ensure plus Yoghust Style

Enshake

Ensure 2 cal

Ensure Plus Crème

Fort isip

Fort isip Compact

Fort isip Compact Fibre

Fort isip Extra

Fort isip M ult if ibre

Fort ijuice

Fort isip youghurt Style

Fort icreme

Fort isip Fruit Dessert

Scandishake

Calogen

Complan Shake

Fresubin

Procal Powder

Procal Shot

Prosource Liquid

Top 5 choices: Ensure Plus Milkshake Style

Ensure Plus Juice

Fortisip

Calogen

Prosource Liquids

What influences your choice?

• Familiarity: 16%

• Previous experience: 6%

• Patient Choice- flavour/style/volume: 50%

• Dietetic advice: 16%

• What’s in stock: 6%

• GP reference: 3%

• Cost: 3%

Do you prescribe or suggest prescription of dexamethasone

for appetite stimulation?

Doses: Course length prior to review:

2mg: 9% < 7days: 31%

2/4mg: 25% 1 week: 36%

4mg: 66% 2 weeks: 29%

4-6mg: 2% According to response: 5%

Often

36%

Sometimes

64%

Never

0%

Do you prescribe or suggest prescription of megestrol for

appetite stimulation?

Often

2%

Sometimes

57%

Never

41%

Doses: Course length prior to review:

160mg: 82% 1 week: 20%

160-320mg: 9% 10-14 days: 65%

400mg: 4% 4 weeks: 15%

What influences your choice of

dexamethasone or megestrol?

• Adverse reaction to/side effects of dexamethasone

(bleeding, DM, PM): 41%

• May use dexamethasone for other reasons (gen. well-

being, bone pain): 10%

• If prognosis shorter use dexamethasone: 15%

• Familiarity with/previous experience of dexamethasone:

24%

• Dexamethasone felt to be more effective: 4%

• Onset of action quicker for dexamethasone: 4%

Do you feel you have received adequate training and education

regarding the provision of nutritional support?

54%

46% Yes

No

What training have you received in

nutritional assessment? • None: 44%

• Limited/Minimal: 8%

• Postgraduate medical training: 10%

• Undergraduate medical/nursing training: 4%

• In-service Training on MUST: 23%

• Training as DN: 2%

• Private study: 2%

• Local dietician training: 4%

• Information from drug reps: 2%

When was this training?

26%

10%

26%

19%

19%

< 1 year

1 year

2 years

2-5 years

>5 years

Standards & Guidelines

Guidelines (i)

• An assessment of nutritional status and its impact should be included in the holistic assessment of all patients and reviewed appropriately. [Level 4]

• This assessment should include exclusion of reversible factors and review of other symptomatology. [Level 4]

• An appropriately validated and reliable nutritional assessment tool should be used where possible. The most valid and reliable tool should be chosen taking into account the patient population. [Level 4]

• All health care professionals performing holistic assessments should have education and training specific to nutrition to allow them to deliver appropriate information and/or make appropriate onward referral. [Level 4]

• Monitoring of patient weight, BMI etc is not recommended in palliative care patients unless there is specific indication to do so. [Level 4]

• When trying to increase calorific and nutritional intake a ‘food first’ approach should be used initially. [Level 4]

• Prescription of oral nutritional supplements should be undertaken on an individual patient basis with consideration of possible benefit, practicality, acceptability to patient and likely compliance. [Level 4]

Guidelines (ii)

• Prescription of oral nutritional supplements should be reviewed on a regular basis. [Level 4]

• Appetite stimulants such as dexamethasone or megestrol should be considered in those patients with cachexia/anorexia/weight loss. [Level 4]

• An individual assessment of benefits and risks of treatment is needed with regular review. Generally dexamethasone is recommended for shorter term use (<6/52) and megestrol for longer term use. Reference should be made to existing MCCN dexamethasone guidance. [Level 4]

• Specialist dietetic advice should be available for all patients and where possible access to a specialist palliative care dietician. [Level 4]

• Tube feeding should be considered in patients where the oral route is compromised. Assessment should be made on an individual patient basis. [Level 4]

• In patients where advancing disease is likely to result in compromise of the oral route for feeding, advanced care planning discussions should take place between patient, carers and the MDT with reference to potential ethical issues. [Level 4]

• A nutritional lead should be appointed within each inpatient specialist palliative care unit who has responsibility for development of a protected mealtime policy, policy making and education/training of staff. [Level 4]

Standards • All patients should have a clearly documented assessment of their nutritional

status in their casenotes. [Grade D]

• All specialist palliative care professionals should be able to apply an appropriate nutritional assessment tool where indicated. [Grade D]

• Protected mealtime policy should exist and this should be adhered to in every inpatient setting. [Grade D]

• Every specialist palliative care inpatient unit should have a specifically appointed nutritional lead. [Grade D]

• Every specialist palliative care inpatient unit should have a nutrition policy. [Grade D]

• The delivery of verbal nutritional advice should be supported by appropriate written information. [Grade D]

• For any patient where dietetic advice is required a clear referral pathway should exist and all staff should be aware of this pathway. [Grade D]

Questions & Comments?