4.8 () Contribution of the dietician and nutritionist to PC

Question 1

List 5 reasons a pall pt may have decreased oral intake in the setting of advanced illness and one intervention that can be used to target each reason.

Answer 1

table 4.8.1

1. psychological stress/depression - antidepressant, counselling
2. altered taste and smell - dietary counselling and identification of food aversions/preferences
3. oral thrush/ulceration - nystatin, nutrient dense cold foods, optimize oral hygiene
4. reduced flow and altered consistency of salvia - artificial saliva, chew gum, lozenges, optimize oral hygiene
5. NV - antiemetics, small frequent meals, avoidance of aversions, consume fluids after meals
6. dysphagia - altered consistency of food - semi solid->puree, nutrient dense supplements, PEG tube
7. respiratory distress - medication before meals, wearing loose clothing, relaxation exercises, small meals and present foods that do not require much chewing
8. Early satiety - maximize food availability, small frequent meals, encourage food consumption when a patient feels at their best
9. Altered bowel function (constipation, diarrhea) - laxaxtives, fluid intake, fibre, increase mobility, antidiarrheals, pancreatic enzymes, avoidance of diary, increase soluable fibre

Question 2

List three common causes of altered taste sensation

Answer 2

disease process
chemo/medication
xrt

Question 3

Dysphagia is a common issue for patients with advanced disease. List three diseases in which dysphagia is common. When is a PEG tube appropriate?

Answer 3

motor neuron disease, alzheimers disease, progressive MS, Parkinsons, head and neck cancer

unable to swallow or eat to maintain nutrition/hydration with long term treatment goals,

to support QOL not only to prolong life

Question 4

A patient you are seeing reports that 1 month ago she weighed 100lbs. She now weighs 89lbs. Is this a significant weight loss? What BMI cutoffs represent mild, mod, severe under nutrition?

Answer 4

Yes- weight loss of >= 10% in 1 month is a significant wt loss (grade 4 according to Subjective Global Assessment)

BMI <20 mild undernutrition, <18 moderate, <16 severe

Question 5

List one way to address the issue of early satiety in patients with a palliative diagnosis

Answer 5

offer energy and protein dense supplements one hour before meals when hunger feelings are strongest. Discourage low calorie fluids ie soups before meals

Question 6

What are two types of diet relevant to trajectory of pall care?

Answer 6

Phase 1: diet meeting nutritional requirements
Phase 2: comfort feeding

Question 7

Name 4 dietietic counselling strategies for pall patients

Answer 7

1. Small frequent quick and easy snacks/meals
2. Modify texture according to symptoms
3. Maximize intake on good days
4. Suppress strong smells that may affect appetite
5. Address dry or sore mouth
6. Ambiance of meals should be enjoyable
7. Fortify food to make them high protein/high calorie (with butter, cream, etc.)
8. Consider oral nutrition supplement/enteral nutrition for those unable to consume solid meals