Food is an important part of love, life and family, and is embedded in our culture and everyday living3. Nutrition and hydration for people requiring care is complex and raises ethical questions. Nutrition and hydration has associated psychological, cultural and symbolic meaning4. Food and fluid need to be culturally appropriate.
Resident’s nutrition and hydration should be constantly under review. This way you can be satisfied that residents needs are being met and adequate nutrition and hydration is being provided1.
If a resident refuses food or fluid, assessment of underlying physical or psychological causes should be undertaken, as these can be improved. For example some residents may be suffering from depression and will stop eating. Another common but often overlooked symptom is mouth pain, or pain caused by ill fitting dentures, or oral candida (thrush). It is also important to assist residents who cannot feed themselves2. The offer of food and fluids via the mouth is essential to basic resident care for those who are not at risk of aspiration or choking.
Malnutrition is defined as ‘a specific nutrient deficiency that produces a measurable change in body function’. The reasons for malnutrition in the elderly are multi faceted, and can be associated with ageing, affecting food intake and body weight. However disease can also exacerbate weight loss and nutritional state. Depression and adverse medication side effects are the leading common treatable causes of malnutrition1.
END OF LIFE NUTRITION AND HYDRATION
The desire for food and fluids declines as the resident reaches the last weeks and days of life and treatment of dehydration at the end of life has few benefits, and may cause more burden4. Dehydration is common, and the resident will become weak and take in less fluid. They will sleep more, and this also results in less intake of fluid. Advanced illness results in a loss of sensation of thirst. Hence urine becomes darker and more concentrated as the kidneys compensate.
Intravenous fluids are invasive, and painful. Evidence suggests people who are dying and are dehydrated are less likely to require an indwelling catheter. Dehydration causes an increase in metabolic by- products and ketones, known to act as an anaesthetic to the central nervous system. Dehydration also means less fluid in the GI tract, less vomiting, and respiratory tract secretions5.
At the end of life, kidney function deteriorates, and the resident may not be able to process fluid resulting in respiratory tract secretions, and oedema5. Studies show there is no benefit on quality or length of life to providing artificial fluid. Management of dehydration requires an individualized approach, and involves the resident, family and staff, and assessment must be made on the benefits of treatment versus the burden 5.
There is no current evidence to support rehydration at the end of life for residents who have lost the ability to swallow and/or has fluctuating consciousness and generally does not improve quality of life or symptoms3&6. Rehydration may lead to fluid overload or prolong the dying process6.
FOCUS OF CARE
The focus of care changes from eating and drinking to the priority of comfort.
This is achieved through:
- quality care, such as meticulous regular mouth cares
- ongoing re assessment
- communication with families
- encouraging family to focus on other aspects of care e.g. reading, spiritual support, massage.
1. National Health and Medical Research Council (2006). Guidelines for a Palliative Approach in Residential Aged Care. Edith Cowan University
3. Lembeck, M. E., Pameijer, C. R., & Westcott, A. M. (2016). The Role of Intravenous Fluids and Enteral or Parenteral Nutrition in Patients with Life-limiting Illness. Medical Clinics of North America, 100(5), 1131-1141.
4. Gent, M. J., Fradsham, S., Whyte, G. M., & Mayland, C. R. (2015). What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ supportive & palliative care, 5(3), 223-231.
5. Good. P., Cavenagh, J., Mather, M., & Ravenscroft, P. (2011). Medically assisted hydration for adult palliative care patients. Cochrane database of Systemic reviews.
6. McAnelly, K (NP). 2015. A palliative care approach to nutrition and hydration. The National rollout of the Palliative Approach Toolkit for Residential Aged Care Facilities. Australian Government Department of Social Services.
