Frequency and Indications of Parenteral Nutrition in an Acute Palliative Care Unit

Abstract

The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37-79), and 9 were males. The mean hospital stay was 7.7 days (range 3-14), and the mean Karnofsky level was 35 (range 10-50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinued the treatment during admission. Four patients (29%) started PN during hospital admission as decided by the staff. Twelve patients (85%) were discharged on PN. One week after hospital discharge, 9 patients were still receiving PN, 4 patients died, and no data were available for 1 patient. One month after hospital discharge only 2 patients of these were still on PN, 2 patients discontinued PN, and 5 patients died. This study shows that decisions to start or to stop PN were individually based on multiple considerations, not only clinical. Goals may vary from expected clinical benefits to compassionate use. The administration of PN should be assessed carefully and individually approached.

When Is Parenteral Nutrition Appropriate?

“…Most reports describing PN use in this population involve single centers with a small cohort of patients. One study, conducted in an inpatient palliative care unit, revealed that 1.8% of patients received PN during their stay in the unit 29 . However, some data suggest that PN use in palliative care may be more common than previously thought, with some variation across counties 20 , 30 .…”

“…From an ethical and legal standpoint, there is no differentiation between withholding and withdrawing therapy 1 . However, once started, PN may be difficult to stop, as withdrawing an element of care carries greater emotional weight than withholding therapy 1 , 29 . Sensitivity to the cultural values and religious beliefs of patients and families is crucial in this situation.…”