To celebrate four years of the EAPC Blog, we’re delighted to re-publish one of our all-time most popular posts
Dr Nicholas Herodotou, Macmillan Consultant Palliative Medicine, (Cambridge Community Services), Luton and South Bedfordshire Community, Luton and Dunstable University Hospital, Luton, UK, explains the background to his longer article published in the September 2012 edition of the European Journal of Palliative Care
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 a 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.
Read the full article in the European Journal of Palliative Care
The article to which this post relates, ‘Artificial feeding in terminally ill cancer patients with bowel obstruction’ by Dr Nicholas Herodotou was published in the September/October 2012 (issue 19.5) of the European Journal of Palliative Care.
If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.
This post was first published on the EAPC Blog on 26 September 2012 and is among the five most-viewed posts in the four years since we launched the blog. If you’re a new follower and missed out on some of our most popular posts, we’ll be re-publishing some of our favourite ‘Golden Oldies’ from time to time. You can also find previously published posts by using the category search, or searching the archives, on the right-hand side of the home page of the blog.