About

➀ Read and Learn

The following course content

Introduction   

In the world of palliative care, individuals dealing with long term chronic or terminal conditions face a myriad of challenges that encompass more than just the physical manifestations of the illness. The complex interplay requires personalized interventions, deep understanding of the diagnoses and empathetic support. Of particular concern is the impact of poor appetites and malnutrition.  

This diminishing desire for food not only exacerbates their current condition, physically, but also poses a substantial concern to their overall well-being. An emphasis is on addressing these nutritional challenges to promote comprehensive holistic and compassionate palliative and end-of-life care (22).  

Palliative Care 

Palliative care is a multidisciplinary, specialized medical care for individuals of any age and living with any serious illness that is either chronic, curable, or life threatening (1). Individuals can better understand their personal choices for medical treatment. Palliative care guides them through all the decisions and potential situations that may occur, allowing them more in-depth and keen understanding (2). 

These patients may receive medical care for symptoms and treatments for these illnesses, but the goal of palliative care is to enhance the quality of life for the individual and for their family by focusing on them and their individual needs (1). This includes offering comprehensive support to address physical, social, emotional, and spiritual needs. This care also focuses on psychosocial support, including counseling, resources, and support groups. The team helps the individuals and their family cope with the challenges and ambiguities associated with their condition. Palliative care is a holistic, personalized care approach.  

The palliative team consists of physicians, nursing, chaplains, and social workers who work collaboratively to ensure that the needs of the individual and their family members are addressed (2). Open and honest communication is key in engaging in direct discussions to ensure medical decisions are parallel with the individual’s values and preferences (2). 

It is important to understand palliative care is not the same as hospice care. Additionally, palliative care is not exclusive to end-of-life situations (1). However, it does offer support to the family and loved ones during the course of illness and bereavement period after the individual’s death (1).  

Appetite 

The hypothalamus, a structure deep in the brain, acts as the brain’s coordination center for hunger and fullness (5). The infundibular nucleus in the hypothalamus allows for substances, such as peptides and proteins to interact with its respective nerve cells.  

These nerve cells trigger neurotransmitters that either induce hunger and allow for weight gain, or feelings of satiety which contribute to weight loss. The collaboration between the neurons and their neurochemical mediators coordinates the delicate balance of the feeling of hunger and fullness (3, 4).  

Appetite-Regulating Hormones 

There are several hormones that regulate appetite, including ghrelin, leptin, insulin, peptide YY (PYY), glucagon-like peptide-1 (GLP-1), and cortisol (5, 6, 10, 11, 14, 15). 

Ghrelin 

Ghrelin is a circulating peptide that is produced in the stomach, often referred to as the “hunger hormone” (5). It stimulates feeding by increasing the NPY and AgRP neurons (5).  Ghrelin (growth hormone releasing peptide) is considered a meal initiator as it rises prior to meals then drops quickly after ingestion of nutrients. It is a good reflector of nutritional status and body fat stores (6). In obese individuals the value is low but in lean subjects the value is high. In individuals with conditions such as cachexia, cancer, chronic cardiac failture, and anorexia nervosa, it is markedly elevated (6).  

Leptin 

Leptin, a hormone released by adipose tissue (body fat), operates on the brainstem and the hypothalamus and plays a vital role by influencing hunger and fullness (8, 9). It hinders unnecessary hunger responses and regulates energy expenditure (8). It influences the body over time rather than over a short time, from meal to meal. The main function of leptin is to help the individual maintain a consistent weight over a prolonged period of time (8, 9). During weight loss, the decreasing leptin levels will signal hunger, leading to increased food consumption and decreased fat mass (9). 

Glucagon and Insulin 

The pancreas secretes the hormones ‘glucagon-like peptide’ and ‘insulin’ and have short-term effects on blood glucose levels (13). Glucagon elevates blood glucose levels by stimulating liver glycogen breakdown (11). Insulin, released by B-cells, signals circulating glucose and stored energy in visceral adipose tissue (13). It regulates glucose through peripheral and central pathways, which maintains homeostasis and supplies energy to tissues and organs (12). Insulin inhibits liver glucose synthesis and some plasma insulin influences the brain, inducing a catabolic response, reducing food intake, and initiating weight loss (12). Once carbohydrates are consumed, the increase in blood sugar triggers the pancreas to release insulin. This action prompts cells to absorb blood sugar for energy or storage. These two hormones work in tandem to maintain a healthy balance of blood sugar levels within the body (11). 

Peptide YY 

Peptide YY exerts its impact on the stomach and intestines, slowing down the movement of food through the digestive system. The presence of food in the digestive tract triggers the release of peptide YY, especially foods rich in fat and protein (14). It functions by binding to receptors in the brain causing a reduction in appetite and general feeling of fullness (14). The amount of peptide YY released into the bloodstream is proportional to the calorie consumption – foods higher in calories prompt a substantial release of peptide YY than lower-calorie foods (14). 

Cortisol 

During times of stress, hormones (like cortisol) cause hyperglycemia which is strongly associated with unfavorable outcomes in hospitalized patients (10). Cortisol, a glucocorticoid released by the adrenal glands, increases appetite and enhances overall motivation, including the drive to eat (15). Following the conclusion of a stressful episode, cortisol levels decrease. However, if the stress is persistent, cortisol levels may stay elevated (15). 

Impact of Appetite on Illness 

Individuals with chronic illnesses, such as those approaching the end-of-life, commonly deal with loss of appetite which often leads to weight loss (7). This weight loss is further complicated by the increased need for essential proteins crucial for healing. Many factors such as underlying diseases (tumor-induced inflammation leading to cancer-associated cachexia), symptoms (pain, constipation, nausea, breathlessness), and decreased energy requirements play a role in this loss of appetite (17).  

Per Ehret and Jatoi (2021), in patients with advanced illnesses, the body systematically shuts down in the end-of-life phase and the gastrointestinal system is predictably the first to be impacted. The body’s natural survival instinct strategically redistributes energy to sustain essential bodily functions. It justifies redirecting energy from food-related processes to the vital organs, resulting in decreased desire to eat. 

Malnutrition 

Early identification of malnutrition risk is vital in providing effective support and improving quality of life for individuals on palliative care. Individuals on palliative care with life limited diseases, like congestive heart failure, cancer, autoimmune deficiency syndrome (AIDS), dementia, and chronic obstructive pulmonary disease (COPD) commonly experience anorexia and cachexia (20). Older individuals frequently encounter negative health outcomes including a drop in physical and cognitive functioning, psychological disorders, and acute/chronic diseases (16).  

Metabolic changes can lead to suppressed appetite and impaired food intake which can lead to malnutrition. However, apart from the medical aspect, malnutrition may also be related to loss of smell, depression, mucositis, chronic gastrointestinal disease or even persistent symptoms such as pain, that may affect an individual’s desire to eat (20). In addition to tiredness and fatigue, changes in appetites due to decreased ability to tolerate solid foods and poor oral intake, are concerning markers of mortality (19).  

Signs and Symptoms 

A thorough examination including the patient’s medical history, disease progression, comfort level, social support, economic status, cultural and religious beliefs, in conjunction to the ethical and legal aspects, must be considered (20). Additional diagnostic assessments may be required should a potential for reversible causes arise (20).  

Common signs and symptoms of malnutrition include (21):  

• Changes in cognitive function  

• Fatigue and weakness (including feeling full quickly) 

• Poor appetite (eating in less quantity) 

• Oral discomfort (pain or dryness, and difficulty chewing) 

• Gastrointestinal issues (constipation, diarrhea, difficulty swallowing, nausea or vomiting) 

• Changes in taste or smell can affect an individual’s food choices 

• Unintentional weight loss can be indicative of muscle wasting and loss of fat stores 

Vitamin Deficiencies 

Patients requiring palliative care often exhibit symptoms common to symptoms of patients with vitamin deficiency. These symptoms include weakness, pain, fatigue, and depression (22). Malnutrition is common in these patients due to factors such as malabsorption, reduced food intake, and metabolic disorders. The most common vitamin deficiencies include C, D, and B1 thiamine, B6, B9 folate, and B12 (22). Per Vollbracht and colleagues (2019), there are significant vitamin C, D3, and B6 deficiency rates in nearly all patients. Therefore, management with vitamin supplements is recommended. 

Treatment 

The dietitian alongside the interdisciplinary team will design a personalized meal plan aimed at the patient’s comfort, maintenance, or recovery. Recommendations mainly include increased calorie and protein intake, eating smaller but more frequent meals, opting for easier-to-chew foods, and considering nutritional supplements such as high protein drinks (21). 

When managing nutrition for individuals on palliative care, specific dietary restrictions are generally not necessary, but the focus should be on diversifying food intake from all food groups. In order to fulfill energy and protein requirements, incorporating more full fat dairy, snack foods, and desserts, instead of fruits and vegetables, is commonly advised (21). The dietitian should be aware of all nutritional, herbal, or vitamin supplements taken as they may impact the effectiveness of concurrent medical treatments and medications. 

Interventions 

According to guidelines by the European Society for Clinical Nutrition and Metabolism (ESPEN), when inadequate oral nutrition persists despite interventions (like counseling), enteral and parenteral nutrition is the next step in deliberation (23). Enteral nutrition is the primary consideration, especially when the gastrointestinal tract is functional. In enteral nutrition, feeding tubes are placed to feed nutrition directly into the stomach.  

Nasogastric tubes – soft tubes that enter the nose and pass down the throat into the stomach – are used temporarily (21). Gastrostomy tubes – tubes surgically placed through the abdomen through the stomach wall – can also be used temporarily or for long term (21). For patients with head or neck cancer and those who are unable to swallow, using an enteral route through a nasogastric tube or gastrostomy tube can be a suitable strategy, especially in the home care setting (23). In patients with esophageal cancer, gastrostomy tubes are associated with better nutritional status and overall prognosis (23). 

In rarer cases, when enteral nutrition is not feasible or contraindicated, intravenous or parenteral nutrition may be recommended. In this route, nutrition is fed directly through the individual’s blood stream without need for oral intake (21). This is commonly seen in dysmotility, intestinal obstruction, abdominal pain/intolerance, peritoneal carcinomatosis, malabsorption, the presence of nutrition impact symptoms (diarrhea, vomiting, nausea, constipation), and bowel resections (23). Vomiting, nausea, and gastrointestinal obstructions were identified as the most common indications for parenteral nutrition in palliative patients (23). In these situations, enteral nutrition may not adequately meet the individual’s nutritional needs.  

Regarding ethics, there has been much debate concerning whether to provide nutrition to palliative patients. Per the bioethics guidelines, the consideration of alternative nutrition should involve a thorough discussion with the patient (23). The most important goal of palliative care is to respect the patient’s autonomy and adhere to legal requirements regarding their choice. Another way to address this situation is by following the patient’s advanced directive (if there is prepared prior documentation) (23). In these conversations, prognosis is one of the most significant conditioning issues and must be discussedas a potential survival benefit in these individuals. 

Patient Education 

The initial goal of all nutritional treatment in palliative patients should be focused on pleasure. This includes encouraging foods that are enjoyable for the individual and easy to chew. However medically, maximizing the individual’s independence and preserving oral nutrition are priorities (23). Per ESPEN guidelines, counseling is an initial approach that can minimize food-related discomfort and maximize food enjoyment (23). Dietitians and speech and language therapists can identify the factors that may hinder the patient’s quality of life. Minor modifications, such as adapting food consistency, size portions, food quality, food temperature, and splitting meals throughout the day, can greatly optimize nutritional intake (23). Open communication and understanding individual’s prognosis and diagnoses can also help with understanding why they may feel this way, which in turn can fuel motivation to intake nutrition.  

Resources 

To further support the individual, Medicare, Medicaid and other insurance policies may cover palliative care services (1): 

• Coverage for veterans through the Department of Veteran Affairs 

• Help in finding a palliative care provider through the Hospice and Palliative Care Organization at https://www.nhpco.org/find-a-care-provider/ 

• Care through your primary care physician 

• Dietitian services 

• Oncologist/oncology nursing services 

• Palliative care programs, which can be found at https://www.cancer.org/cancer/managing-cancer/palliative-care/how-to-find.html  

• Additional resources (like recipes), which can be found at https://www.cancernutrition.org  

Conclusion

Palliative care is a comprehensive approach to enhance quality of life and provide support by addressing the psychosocial, emotional, and spiritual needs of an individual living with illnesses. Open and honest communication plays a pivotal role in aligning medical decisions with patient goals, allowing for autonomy and dignity in care.  

Nutrition is an integral part of palliative care and is managed by supporting overall well-being. This may be done through education and treatments that include personalized meal plans and dietary adjustments. These recommendations are suggested to patients to optimize nutritional intake while respecting individual preferences and cultural beliefs. There is a complex interplay between physical symptoms, psychosocial factors, and spiritual and emotional well-being. By fostering a collaborative approach to care, we can provide individuals receiving palliative care optimal support and comfort they need during such challenging times. 

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate