Nutrition and Hydration

Purpose: Review of resident’s needs

and comfort or distress related to
nutrition and hydration during the
final stages of life and review of
regulatory guidance on the use of
parenteral and enteral feeding.
 Objectives
• Understand that nutrition and hydration goals are
based on the needs and wishes of each
resident/surrogate.
• Recognize the IDT’s responsibilities to help the
resident meet all nutrition and hydration needs.
• Know that although food and hydration usually
provide comfort and nourishment, in the end
stages of life they may cause distress.
 Objectives, cont.
• Maintain regulatory compliance with
nutrition, hydration and artificial feedings.
• Provide families with information and
support regarding nutrition and hydration at
the end-of-life.
 In Accordance with the
Comprehensive Assessment and
Plan of Care
World Health Organization (WHO)

Palliative care defined as “active total care

of patients whose disease is not responsive
to curative treatment…..”
 Goal of Palliative Care
WHO

Goal of palliative care is to achieve “the

best quality of life for patients and their
families.”
“The regulatory requirement for the
resident to achieve the highest level of
well-being in accordance with the
comprehensive plan of care applies to
any resident at any time during his or her
stay and the LTC facility.”
 Appropriate Nutrition and
Hydration Goals

“The primary goal of nutrition and hydration

in terminal illness is comfort-improving
quality of life by giving the resident
maximum enjoyment from eating.”
 Appropriate Nutrition and
Hydration Goals, cont.

“Another goal is to maintain the resident’s

nutritional status or optimize the resident’s
intake.”
Goals Difficult to Balance in
LTC
 IDT Members
• Registered Dietician (RD)
• Dietary Manager
• Occupational Therapist
• Physical Therapist
• Charge Nurse
• Nurse Assistant
• RAI/MDS Coordinator
• Pharmacist
• Physicians
 Inappropriate Nutrition and
Hydration Goals
“Tradition goals of a balanced diet and
achieving an ideal weight are not realistic or
appropriate in end stages of life.”

“Traditional diets that restrict salt,

cholesterol, or sugar may no longer be
appropriate unless the resident prefers the
restriction.”
 Comfort versus Distress
• Primary goal always comfort!
• Highly individualized
• “One size fits all” care planning won’t work
• End-of-life to “imminent death” – broad
category
• What brings comfort in early stage will
bring distress is later stage.
• Staff must be aware of ongoing changes
 Comfort versus Distress, cont.
• Offer frequent, smaller feedings.
• Cravings change from one moment to the
next.
• Never make the resident feel guilty for not
trying to eat.
• Forcing food and fluid can cause distress.
• Intake during the dying process does not
improve the quality of life.
 Comfort versus Distress, cont.
• Dehydration prevents distressing symptoms
• Dehydration is not painful
• Dehydration described as euphoria as
endorphins are released
• Dry mouth and membranes will cause
distress if not managed.
 Nutrition and Hydration
Regulatory Guidelines
State Operations Manual, Appendix P
Investigative Protocol
“If a resident is at end of life stage and has an
advance directive, according to state law, or the
resident has reached an end of life stage in which
minimal amounts of nutrients [fluids] are being
consumed or intake has ceased, and all appropriate
efforts have been made to encourage and provide
intake, then weight loss [dehydration] may be an
expected outcome….”
 Nutrition and Hydration
Regulatory Guidelines, cont.
Directions to surveyors, cont.
“Conduct observations to verify that
palliative interventions, as described in the
plan of care, are being implemented and
revised as necessary, to meet the
needs/choices of the resident in order to
maintain the resident’s comfort and quality
of life.”
 Medications

First, all medications should be reviewed to

ensure that they are necessary given the
resident’s changing condition. Then
medications that might improve appetite can
be considered.
Medications to Improve Appetite
• Steroids
• Megace (megestrol)
• Periactin (cyproheptadine)
• Remeron (mirtazapine)
• Marinol (dronabinol)
• Pain control medications
 Parenteral and Enteral Feedings
Benefits and Burdens
• Discuss with resident and family
• Specialized roll in head and neck or
esophageal cancers
• High incidence of aspiration, self-removal,
and restraints
• Symptoms such as nausea, rattling
pulmonary secretions, and diarrhea
 Parenteral and Enteral Feedings,
cont.
• GI system fails to absorb food at end of life
resulting in weight loss, abnormal labs, and
pressure sore development.
• Fluid overload can occur with artificial fluids,
which can hasten death and aggravate the dying
process.
• In case of doubt, a short trial of rehydration may
be appropriate to flush drug by-products in cases
of mental confusion.
Regulatory Compliance in the
Use of Feeding Tubes
42 CFR 483.25. (g) F321
Nasogastric Tubes
“Based on the comprehensive assessment of a
resident, the facility must ensure that a resident
who has been able to eat enough alone or with
assistance is not fed by naso-gastric tube unless
the resident’s clinical condition demonstrates that
use of a naso-gastric tube was unavoidable.”
 Regulatory Compliance in the
Use of Feeding Tubes
Resident Assessment Protocal (RAP)
Feeding Tubes
“…..informed consent is essential before inserting
a feeding tube. Potential advantages,
disadvantages, and potential complications need to
be discussed. Resident preference is normally
given the great weight in decisions regarding tube
feeding…. technical means of providing fluids and
nutrition can represent extraordinary rather than
ordinary means of prolonging life.”
 Family Attitudes
• Eating and drinking as symbolic gesture of
giving love
• Food as a celebration and social event
• Refusing foods may be perceived as
refusing love
• Help family refocus energy by providing
nourishment for the mind and spirit
• Help family find meaningful ways to visit
 Family Attitudes, cont.
Ways to visit meaningfully:
• Apply lotion to hands and feet
• Give a back massage
• Apply moisturizer to the lips
• Remember earlier times and happenings
• Play audio tapes of nature sounds and music
• Talk about past life memories/experiences
• Sit in silence and share the time
 When Staff Become Family
• Be aware of one another’s emotional attachment to
dying residents
• Staff become surrogate family
• Nurture caring relationships, allow for grief
• Grief counseling services for staff and families
• Manage all aspects of death and grieving in a
healthy manner.
• Everyone needs good memories and support as
they deal with difficult situations of living and
helping others during their time of dying.