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NUTRITIONAL UPDATE/FEEDING AND END-OF-LIFE CARE
Audio-Digest Gastroenterology
Volume 27, Issue 14
July 21, 2013

Updates on In-hospital Nutritional Support – Robert G. Martindale, MD, PhD
Ethics of Feeding: Decision Making in End-of-Life Care – Stephen A. McClave, MD

   
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Gastroenterology Program Info  Accreditation InfoCultural & Linguistic Competency Resources

Nutritional Update/Feeding and End-of-Life Care

Educational Objectives

The goal of this program is to improve the care of patients who require enteral feeding. After hearing and assimilating this program, the clinician will be better able to:

1. Implement protocols for early enteral feeding.

2. Evaluate the appropriateness of standard vs specialized enteral formulas.

3. Discuss the diverse benefits of fish oil supplementation.

4. Review the ethical concepts associated with end-of-life decision making.

5. Cite current data on percutaneous endoscopic gastrostomy (PEG) tube feeding.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Updates on In-hospital Nutritional Support

Robert G. Martindale, MD, PhD, Professor and Chief, Division of General Surgery, Oregon Health & Science University School of Medicine, Portland, OR

Introduction: malnutrition redefined in 2010 according to cause, divided into 3 types; 3 types of malnutrition — malnutrition related to starvation (eg, anorexia nervosa, no inflammation); malnutrition related to chronic disease (mild to moderate inflammation); malnutrition related to acute disease or traumatic injury (severe inflammation); patients require different tests depending on type of malnutrition; certain diagnostic tests more valuable from one patient to another; albumin — measuring albumin levels in setting of intensive care unit (ICU) not helpful, but preoperative measurement of albumin level best predictor of perioperative outcome

Caloric deficit as indicator of outcome: studies have shown that caloric deficit of 5000 calories during first wk in ICU (Villet, 2005), or even 4000 calories in first wk (Singer, 2006), increases likelihood of negative outcomes (eg, length of stay, mortality, complications); study showed that enteral feeding achieved only 50% of patients’ caloric nutritional goal; conclusions — patients who come to hospital in well-nourished state do not require total parenteral nutrition (TPN) during first 5-7 days; patients who enter hospital in malnourished state and cannot receive nutrients through GI tract should receive early (24-48 hr) parenteral feeing

Enteral feeding protocols: institution of protocols probably most important single step to help clinicians meet patients’ daily protein and caloric goals; Heyland study reported success rates of up to 83% of calories and 89% of protein when protocol adopted; mortality benefit associated with adopting early enteral feeding protocol in ICU; protocols at speaker’s institution initiate feeding within 24 hr unless specific “do not feed” instruction

Enteral feeding formulas: >200 formulas approved for use in United States; not regulated by Food and Drug Administration due to status as medical foods; protein sources — examining protein source important for health of hospitalized patients; formulas that use whey-based or casein-based protein sources considered superior to soy-based protein; peptide formulas may be beneficial in patients with compromised brush border (no evidence from prospective randomized trial); fiber — insoluble fiber should be avoided in ICU setting due to potential for obstruction from fluid flux; soluble fibers should be included in diet of all patients; pearl — standard formulas appropriate for 75%-80% of hospitalized patients, but ICU patients may require more specific diet and specialty formulas; theory behind formulas for patients with renal failure — these patients have compromised ability to clear nitrogenous wastes from their bodies, so require formulas that provide high levels of essential amino acids and low levels of nonessential amino acids; these formulas also low in potassium and phosphate; newer theory on patients with renal failure — should provide reasonable protein, because acute kidney injury and acute renal failure respond more rapidly with adequate protein; National Institutes of Health (NIH) consensus conference recommended that these patients should receive 1.5 g of protein per kg of body mass per day (ie, protein should not be restricted); hepatic formulas — in liver failure, high levels of aromatic amino acids and low levels of branched chain amino acids (BCAAs) in serum lead to hepatic encephalopathy (HE); increased levels of aromatic amino acids in brain result in production of false neurotransmitters (octopamine); 93% of patients with liver failure and HE clear their encephalopathy within 24 hr when fed formula containing high levels of BCAAs; however, these BCAA formulas do not help liver, only provide temporary relief from HE; pulmonary formulas — no prospective randomized trial to support efficacy of these formulas in hospital patients; some data to support use in outpatient setting; immune-modulating formulas — research shows these formulas beneficial in appropriate population; diabetes formulas — scant research to support use; inflammatory bowel disease (IBD) formulas — new formula not yet approved for use in United States (expected within yr)

Fish oils: mechanisms of action — biochemical and clinical research clearly indicates benefits of fish oil supplementation; fish oils reduce inflammation by altering ratio of prostaglandins (increases levels of prostaglandin E3, less inflammatory than E2); shown to enhance diaphragm function and decrease expression of intracellular adhesion molecule 1 (ICAM1 part of first step in microvasculature thrombosis); can help maintain bowel motility by altering vagal regulation of inflammation in gut (feedback mechanism from GI tract to brain); endotoxin study — infused healthy volunteers with IV fish oil for 1 hr, then gave IV dose of Escherichia coli endotoxin; study concluded that IV fish oil supplementation lowered virtually all measured metabolic responses to insult (eg, adrenocorticotropic hormone, cortisol, cytokines, norepinephrine, temperature) by 14% to 34%; fish oils reduce loss of lean body tissue after catabolic insult; fish oil and cardiac events — Japanese study of 18,000 patients found that fish oil supplementation of 2 g per day associated with 19% reduction in incidence of major coronary events in patients with hypertension or high cholesterol; study showed that 2 g of fish oil per day for 5 days prior to cardiac surgery resulted in 54% risk reduction in rate of atrial fibrillation after surgery; study performed in porcine model showed that fish oil reduced infarct size and mortality when administered after acute myocardial infarction; pearls — fish oil considered standard of care in pediatric patients with parenteral nutrition-associated liver disease; conflicting data on efficacy of fish oil in patients with IBD; studies in animal models with disease similar to familial polyposis in humans show that parenteral fish oil decreases number and size of polyps (large NIH trial on humans under way)

Amino acid supplementation: supplemental arginine — use of arginase increases during times of stress and diverts arginine from nitric oxide pathway (nitric oxide major vasodilator in tissue); deficiency in substrate can lead to inadequate vasodilation and ischemia; supplementing arginine during times of stress provides more input for both arginase and nitric oxide pathways, ensuring adequate vasodilation; supplemental glutamine — glutamine supplementation increases intracellular levels of heat shock protein (HSP); has anti-inflammatory and antioxidant effects; produced in response to stress; large doses of antioxidants — study found that large doses not beneficial; can nullify benefit of exercise, because mitochondria need to experience some stress to trigger increased biogenesis

Exercise and nutrition: stays in hospital “unload” patients’ muscles; studies concluded that hospitalized (including ICU) patients benefit from exercise during stay and that exercise program safe; speaker’s institution has program to enable patients on ventilators to walk; also uses devices that strap on for leg exercise in bed; exercise decreases LOS in ICU and hospital; moving and stressing muscles increases metabolization of supplemental nutrition

Ethics of Feeding: Decision Making in
End-of-Life Care

Stephen A. McClave, MD, Professor of Medicine, University of Louisville School of Medicine, Louisville, KY

Basic principles of medical ethics: all 4 major areas of medical ethics involved in tube feeding issues and end-of-life decisions; autonomy — patient autonomy (adult is final arbiter of own life) top factor in these cases; forcing medical care upon patient who does not want it violates patient autonomy; physician can ethically find other clinician to perform certain actions as long as no lapse in care occurs; beneficence and nonmaleficence — beneficence dictates that intervention should provide net good to patient; nonmaleficence dictates that physicians should do no harm; futility — medical intervention would have no beneficial effect on patient; justice — equal and fair allocation of medical resources across community; poor patients more likely to receive percutaneous endoscopic gastrostomy (PEG) therapy than wealthy patients; PEG study — retrospective study found that 43% of patients died within 1 wk of PEG tube placement; authors recommended that committee should review which patients would benefit from PEG tube (trying to uphold ethical principle of futility); speaker argues that committee procedure could violate principle of justice and prevent fair distribution of medical resources across community

Attitudes during 1970s: TPN introduced in 1968; acknowledgment of widespread malnourishment; nutrition should be provided regardless of patient population, disease process, or clinical prognosis; physicians believed to have obligate moral and ethical requirement to feed all patients (ordinary care, basic necessity); paternalistic doctor-patient relationship (patients should follow physician’s directives); withdrawal of nutrition, rather than disease, considered to result in patient’s death; withdrawal of nutrition and hydration perceived to result in painful death

Four crucial court cases

Quinlan case: after drug overdose, young female patient placed on mechanical ventilation and PEG feeding; parents wanted to stop ventilator but did not ask to stop tube feeding; patient lived another 9 years after cessation of mechanical ventilation; New Jersey Supreme Court ruled that family has right to forgo life-sustaining therapy for incompetent family member

Barber case: middle-aged man entered hospital for elective closure of ileostomy; patient aspirated and sustained anoxic brain damage; spouse asserted that husband did not want feeding tubes or mechanical ventilation (patient had no living will or designated power of attorney); feeding stopped and patient died; disgruntled nurse called authorities, and two doctors convicted of murder; appellate court disposed murder charges (physicians had no “duty to act”)

Bouvia case: young bedridden immobile female patient with severe cerebral palsy; completely cognizant; patient requested feeding tube be removed; appellate court determined that patients have fundamental right to refuse medical treatment (autonomy meaningless without right to refuse therapy)

Cruzan case: young woman suffered severe anoxic brain damage after motor vehicle accident, placed on PEG feeding; patient given life expectancy of 25 to 30 yr; parents sought to stop PEG feeding; Missouri courts ruled that feeding cannot be stopped without convincing evidence that patient would have wanted feeding to stop; US Supreme Court upheld decision, ruling that feeding obligatory unless evidence could show that patient would have refused PEG feeding

Conclusions from case precedents: patient autonomy most important factor in end-of-life decisions; patients have right to accept or reject therapy; right to accept therapy meaningless without right to reject therapy; providing unwanted medical care diminishes patient dignity; criminal liability eliminated; legal concept of “but for causation” flawed; nutrition and hydration indistinguishable from other life-sustaining therapies; court does not distinguish between invasive and noninvasive techniques; withdrawal of treatment no different from act of provision

Ethics in placement of PEG tube: benefits from PEG therapy differ from one patient population to next; PEG therapy beneficial to patients who have had stroke; patients with reversible disease process who require >4 wk of nutritional therapy considered good candidates for PEG therapy; PEG therapy has little to no benefit in patients with end-stage metastatic cancer (complications from PEG may be harmful to these patients); PEG therapy in patients with dementia highly controversial; PEG therapy does not appear to decrease patient’s likelihood of getting pressure sores; PEG therapy reduces aspiration events in patients with dementia when compared with patients receiving nasogastric feeding; quality of life (QOL) — PEG therapy eliminates personal interaction that occurs during oral feeding of patients with dementia; one study showed that among patients who could communicate, 33% reported that PEG therapy improved QOL, 33% reported that it diminished QOL, and 33% reported no change in QOL with PEG; majority (68% to 80%) of families and caregivers report increase in QOL with PEG feeding (less frustration); mortality — PEG feeding does not affect patient’s mortality; mortality related to patient’s underlying disease process; crucial to discuss goals with family before placement of PEG tube

Acknowledgements

Drs. Martindale and McClave spoke at the 17th Annual Medical and Surgical Approaches to GI Disorders, held July 16-20, 2012, in Kiawah Island, SC, and sponsored by Medical College of Georgia at Georgia Health Sciences University. For future CME activities by the Medical College of Georgia, visit their web page: www.georgiahealth.edu/ce/medicalce/2013/. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Suggested Reading

Dvir D et al: Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr. 2006 Feb;25(1):37-44; Fleck A et al: Clinical and nutritional aspects of changes in acute phase proteins during inflammation. Proc Nutr Soc. 1989;48:347-354; Gibbs J et al: Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999 Jan;134(1):36-42; Heyland DK et al: Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care. 2010;14(2):R78; Martindale RG et al: Guidelines for nutrition therapy in critical illness: are not they all the same? Minerva Anestesiol. 2011 Apr;77(4):463-7; McClave SA, Heyland DK: The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract. 2009 Jun-Jul;24(3):305-15; Miller KR et al: “CAN WE FEED?” A mnemonic to merge nutrition and intensive care assessment of the critically ill patient. J Parenter Enteral Nutr. 2011 Sep;35(5):643-59; Pluess TT et al: Intravenous fish oil blunts the physiological response to endotoxin in healthy subjects. Intensive Care Med. 2007 May;33(5):789-97; Singer P: Toward protein-energy goal-oriented therapy? Crit Care. 2009;13(5):188; Yokoyama M et al: Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet. 2007 Mar 31;369(9567):1090-8.


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