Dr Nicholas Herodotou, Macmillan Consultant Palliative Medicine, (Cambridge Community Services), Luton and South Bedfordshire Community, Luton and Dunstable University Hospital, Luton, UK
It is not uncommon for terminally ill patients (deemed as being in the last weeks of life) to be neglected with regard to artificial feeding and interventional procedures such as venting gastrostomy. This may be partly due to the wrong assumption that a patient who is not for cardio-pulmonary resuscitation will, by default, not receive any active treatment.
In any procedure given to a terminally ill patient, the ethical balance of harm versus good is finely balanced. In some cases, a procedure such as artificial nutrition may prolong life by maintaining calorific input, but this could also prolong the patient’s suffering as a consequence. In some cases, artificial nutrition can accelerate death due to complicating factors. The key aim of considering artificial nutrition in this select group of patients is whether providing artificial feeding via a PEG (percutaneous endoscopic gastrostomy)or TPN (total parenterel nutrition) will enable them to regain their ‘energy’ for a short period.
I became concerned that some patients with irreversible malignant bowel obstruction were managed in hospital for days with intravenous fluids without consideration for nutritional input. First, this can result in increased fatigue, partly due to reduced calorific input as well as delayed discharge. Second, patients with persistent vomiting due to the same condition were being discharged home on a syringe driver but with poor symptom control. Often, these patients had to be terminally sedated which limits quality time with family and friends and can, for example, prevent the patient dealing with their financial affairs. As there was no agreed pathway within the hospital trust in managing this select group of patients, I developed a hospital pathway for both artificial nutrition and venting gastrostomy. Often a ‘bad death’ can be the spearhead for service development, which is the reason for these pathways being implemented and the subsequent publication of my article in the European Journal of Palliative Care. The case reports in my article also highlight the ethical complexity of any interventional procedure with poorly published evidence base, but this must never be a deterrent to enhancing patient centred care, if the benefit outweighs the harm.
Case study – one
A young man in his thirties was diagnosed with malignant bowel obstruction and was actively mobile and hungry. Because he was unable to eat, oral input was not an option. He desperately wanted to remain alive to see his fifth child born. He was eventually given home parenteral nutrition and survived four months, enabling him to see his son born.
Case study – two
A young patient diagnosed with linitus plastica, developed profuse vomiting due to her gastric tumour. My attempt to get a venting PEG inserted by the surgeon failed, resulting in this patient dying badly at home. This led me to develop a hospital pathway for artificial nutrition for palliative patients as well as a venting gastrostomy pathway for irreversible malignant bowel obstruction. This has had significant impact on the quality of life with respect to stopping vomiting and enabling a patient to have small amounts of oral nutrition for pleasure. Previously, profuse vomiting not controlled by a syringe driver would result in the patient having to be sedated. A venting PEG allows a patient to be discharged to their preferred place of dying with dignity. Both the artificial nutrition and venting PEG pathway have enabled professional collaboration between the hospital doctors, nutrition and palliative care team, and together these have enhanced patient care.
Find out more…
The article to which this post relates, ‘Artificial feeding in terminally ill cancer patients with bowel obstruction’ by Dr Nicholas Herodotou, is published in issue 19.5 (September/October 2012) of the European Journal of Palliative Care. If you already have a web-based subscription to the EJPC you will be able to download and print this issue plus all articles in the EJPC archive.
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