Abstract
In Diet and Nutrition in Palliative Care Medicine, the authors provide evidence-based nutritional guidance for the palliative care patient. Although the goal of many nutrition textbooks is to advise clinicians in restoring patients to full health, this text provides a comprehensive review of end-of-life nutrition wherein the expected prognosis can range from weeks to years. During this time, nutrition may be one of the most important factors for improving quality of life and easing suffering. This text presents a wealth of research across the life span and describes cultural and religious factors that should be considered in the care of patients from diverse traditions.
The greatest strength of this book lies in its coverage of certain controversial issues surrounding nutrition at the end of life, including artificial hydration and nutritional support. Robin L. Fainsinger, a professor of palliative care, references research that artificial hydration is not helpful for reducing thirst for advanced cancer patients at the end of life. Hunger, thirst, and dry mouth can all be managed with effective mouth care and hand-proffered oral hydration. However, no hydration at all, or a fluid deficit, may alternatively increase agitated delirium and provoke acute kidney injury. Fainsinger's research found that agitated delirium seems to be less prevalent wherein parenteral hydration is part of the palliative care practice at the end of life. Fainsinger reports that the three large-scale reviews on this topic were unable to draw conclusions that can be applied to clinical practice. Of note, in 2013, the Academy of Nutrition and Dietetics published an article on ethical and legal issues in feeding and hydration, claiming a lack of benefit of artificial nutrition during the last days of life. Thus, individual circumstances should be thoroughly considered when evaluating the use of artificial nutrition in the dying patient.
Nutritional support can be defined as either enteral nutrition, which is any method of feeding using the gastrointestinal tract, or parenteral nutrition (PN), wherein the patient is fed intravenously. Authors Amy Abernethy and Jane Wheeler discuss the complex decision about utilizing versus foregoing total PN in people with advanced malignancies. The authors advise that PN is not recommended in the terminally ill cancer patients. However, the research presented is more than 10 years old, when chemotherapy and treatment regimens were much different than they are today. PN has been proven to be beneficial in patients in certain settings, such as in those patients who have received bone marrow transplantation in the setting of protein malnutrition. However, although PN has clinical utility in certain situations, risks as well as benefits should be considered. The decision to initiate home PN should include the caregiver burden of administering PN. In some cases, nutritional support can maintain comfort and quality of life as malnutrition can be uncomfortable. This textbook skillfully discusses the difficult task of determining prognosis as well as involving the patient's goals and values when weighing the benefits or risks of artificial nutrition.
Of particular interest were the chapters discussing cachexia, including the concept of cachexia-related suffering (CRS) in chronically progressive diseases, and also cancer cachexia syndrome in patients with malignancy. CRS is defined as the negative emotional experience associated with reduced nutritional intake and weight loss. Authors report an estimated 50% of patients suffering from weight loss and loss of appetite are affected by CRS. In addition, 9 out of 10 caregivers are estimated to be effected by CRS. This book investigates this innovative concept and brings it into the awareness of palliative care clinicians.
The chapters on olfaction and taste explore why the impact of advanced disease on these senses may diminish oral intake. Suggestions for improving taste include adding flavor to foods, warming food to activate thermosensitive molecules in the taste transduction pathway, and ensuring a pleasant texture and appearance of food to improve palatability. Authors suggest zinc supplementation to improve taste in patients treated with chemotherapy as some chemotherapy agents bind zinc, resulting in inhibition of sensory receptor cells. Patients with taste changes are often drawn to more salty, savory, or sweet foods and can frequently benefit from soft or moist foods. In these situations, registered dietitians (RDs) can be essential team members by providing individualized suggestions for ingredients, food preparation, and recipes that may help perk up taste buds and improve quality of life.
Diet and Nutrition in Palliative Care Medicine would benefit from providing specific instruction for patients and caregivers. A RD can be a core member of the interdisciplinary team. RDs specializing in oncology can provide patients and caregivers with the food-specific information they are seeking, while easing anxiety and providing realistic expectations surrounding their nutrition as illness advances. This text has presented important points drawn from the literature, but it lacks explicit suggestions that can be given to a patient and families. The recommendation to completely exclude entire food groups can be difficult for patients, and may eliminate a significant source of needed calories. Despite this, this text is a valuable resource for palliative care clinicians working with the seriously ill patient population.