Nutritional Issues in End of Life

Question 1

refers to tube feeding and/or intravenous fluids as a medical therapy

Answer 1

artificial nutrition and hydration (ANH)

Question 2

condition expected to lead to death

Answer 2

terminal

Question 3

the process of terminating life-sustaining treatments

Answer 3

withdrawal of care

Question 4

describes patients or family’s wishes regarding resuscitation

Answer 4

code status

Question 5

all efforts to resuscitate patient should be made, including CPR and mechanical ventilation

Answer 5

full code

Question 6

customizable, may desire CPR, but no mechanical ventilation or vise versa

Answer 6

limited code

Question 7

allows death to occur without intercession

Answer 7

DNR/DNI

do not resuscitate/do not intibate

Question 8

appoints individuals to make health-related decisions hen an individual is incapacitated

Answer 8

health care proxy
- health care power of attorny

Question 9

defines patients wishes for medical treatment in case of coma, terminal illness, or persistent vegetative state

Answer 9

living will

Question 10

ne document defining wishes regarding specific treatments and medical care

Answer 10

physicians orders for life sustaining treatment (POLST)

Question 11

Any nutrition and/or hydration support of an invasive nature requiring placement of a tube into the alimentary tract or parenterally via intravenous or subcutaneous means

Answer 11

artificial nutrition and hydration (ANH)

Question 12

Is withholding or withdrawing ANH the same as denying food and drink?

Answer 12

no

Question 13

can patients refuse hydration

Answer 13

yes

Question 14

provides physical symptom management, emotional support, and spiritual comfort when no curative therapy is available or after making the decision to no longer continue curative or life-prolonging therapies

Answer 14

palliative care

Question 15

integrates palliative care into focus on relieving the substantial symptom burden patients face at the end of life, as well as advanced care planning needs, existential concerns, and family and social stressors

Answer 15

hospice care

Question 16

palliative care is_______ management and designed to improve quality of life
- utilized for serious and chronic diseases
- can be used concurrently with curative treatment

some examples?

Answer 16

symptom

anxiety, depression, loss of appetite, pain, nausea, diarrhea, shortness of breath, difficulty sleeping

Question 17

Central ethical question: is it painful not to have access to food & water when dying?
* Hospice professionals have long observed that terminally ill patients experience ______ hunger & thirst and stop eating and drinking
* The analgesic theory proposes that starvation increases production of ______ which may have an ______ effect

Answer 17

no

decreased

ketones

anesthetic (calming)

Question 18

Artificial hydration can cause discomfort from increased _______ and _________ from fluid retention
* Thought that most discomfort is due to ______=> alleviate with ice chips, sips of favorite beverages, and good mouth care

Answer 18

urine output
respiratory distress

dry mouth

Question 19

ANH in ______ includes Alzheimers, Parkinson’s, alcohol-related, and other etiologies.

• progressive cognitive and physical decline
• dysphagia and inability to self-feed are normal sequelae
• discuss nutrition implications early in disease development

hand feeding?

Answer 19

advanced dementia
hand feeding can help these patients

Question 20

Placement of _______ is typically the method of choice for long-term tube feeding
* No proven long-term benefits for individuals with advanced dementia
* Does not reduce _______
* Increases morbidity & mortality
* Often result in=> increased discomfort, use of physical or chemical restraints, increased risk of pressure ulcers, and compromised human dignity

Answer 20

PEG tubes

aspiration

Question 21

Why are PEG tubes often placed?
* Lack of knowledge of risks vs. benefits
* Belief by health care professionals that they will reduce morbidity & mortality
* Demands of ____________
* Fear of __________

Answer 21

family members

lawsuits

Question 22

Oral feeding should be advocated whenever possible
* Patient’s ____________ of food should be primary consideration. Family & staff should be encouraged to assist in feeding the patient
* Diet restrictions should be individualized or liberalized
* Suboptimal oral feedings may be more appropriate than tube or parenteral feedings

Answer 22

emotional enjoyment

Question 23

absence of responsiveness & awareness due to overwhelming dysfunction of the cerebral hemispheres, with sufficient sparing of the brain stem to preserve autonomic & motor reflexes

Answer 23

vegetative state

Question 24

vegetative state caused by _________

Patients may have reflexes, including eye movements, yawning, and involuntary movements, but show no awareness of __________

Answer 24

brain injuries

self or environment

Question 25

Patients who remains in a vegetative state for > 1 month=> __________

Answer 25

Persistent Vegetative State (PVS)

Question 26

If remain unconscious for > 3 months (if non-trauma cause ) or > 1 year if trauma is the cause are deemed in a __________

Answer 26

permanent vegetative state

Question 27

If remain unconscious for > ____ months (if non-trauma cause ) or > ___ year if trauma is the cause are deemed in a permanent vegetative state

Answer 27

3 1

Question 28

One of the most difficult decisions facing health care providers & families is whether to place or remove a PEG tube in a PVS patient * Current findings/conclusions * Consciousness appears to be a prerequisite for suffering * Neuroscience supports that PVS patients _________

Answer 28

do not suffer

Question 29

Terri Schiavo Case * Patient in PVS for ___ years * No advanced directive was left, principle of substituted judgment was applied

Answer 29

15

Question 30

Many believe it is more acceptable to _____ a treatment than to _____ it * No ethical or legal distinction between them * However, the decision to _____ ANH can be more psychologically distressing to family and practitioners * A decisionally capable person may refuse any form of life-saving treatments

Answer 30

withhold withdraw withdraw

Question 31

Be a patient advocate - RDN may be able to best express the needs and wants of the patient and family since the RDN is the main conversation partner for issues related to nutrition * Provide ____ that reduce the side effects of medicine and treatment * Encourage families to suggest the patients favorite meals, when appropriate, and participate in ____ feeding

Answer 31

meals hand

Question 32

for pediatric patients, ____ generally responsible for decision-making - withdrawal/withholding of ANH to infants is particularly difficult because they lack autonomy to ______ in any way ___ exist to prevent abuse-related withdrawal/withholding of ANH

Answer 32

parents feed themselves laws

Question 33

Collaborate with health care team to make ___________ recommendations * Facilitate policy-making and become involved in the institution’s ethics committee * Enhance health literacy about ANH – benefits & burdens * Consider ________ diversity concerning life-sustaining treatments

Answer 33

nutrition & hydration cultural and religious

Question 34

the rules and standards governing the conduct or members of a profession

Answer 34

ethics

Question 35

- the study of the controversial ethical issues emerging from new situations and possibilities brought about by advances in medical technology - encompasses theoretical, clinical, regulatory and policy/cultural domains - what can be done (the technology) vs. what should be done (ethics) vs. what must be done (law)

Answer 35

bioethics

Question 36

A patient with intact decisional capacity may refuse ANH even if medically recommended.

Answer 36

autonomy

Question 37

A nutrition support professional may recommend a temporary PEG tube for patients undergoing chemotherapy and radiation of gastric cancer.

Answer 37

beneficience

Question 38

A nutrition support professional may recommend against ANH in a patient if it decreases quality of life and outcomes.

Answer 38

Non-maleficence

Question 39

Lack of access to appropriate hospice and palliative care may lead to overuse of ANH in disadvantaged cohorts.

Answer 39

justice

Question 40

Communication & Compassion * Some families will request that “everything be done” * Effective ___________ can help prevent ethical dilemmas * Explain risks and burdens of ANH * Clinicians are not obligated to provide futile treatment * Judgment of what is “futile” considers goals of care, proposed treatment, the outcome

Answer 40

communication