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Palliative feeding for comfort guidelines

Introduction

Nutrition is a key priority for healthcare organisations and providing oral intake of food/drink is often an important issue for carers. Managing the risks of oral intake for patients with eating and swallowing problems is important in terms of safety, but can be a challenging ethical dilemma for healthcare professionals and carers (Hansen 2013).

Some patients will present with oral or pharyngeal stage swallowing difficulties (dysphagia) and can be at risk of choking or aspiration. Other patients can lose interest in food at the end stage of life and those with end stage dementia may lose the ability to recognise food (Evans and Best 2015).

The risk of malnutrition and dehydration needs to be assessed in all patients. Healthcare professionals have a duty to provide appropriate nutrition and hydration for patients in their care (NMC 2015, GMC 2010). This document gives advice and guidance on decision making regarding nutrition and hydration in patients who are no longer able to tolerate enough oral food and fluid to meet their nutritional requirements. The Department of Health (2014) states that all staff in contact with patients should be trained in the appropriate use of hydration at the end of life and how to discuss this with patients, their relatives and carers.

Deciding whether to introduce artificial nutrition and hydration (ANH) or to continue to allow food and drink orally once a swallow becomes unsafe, can be challenging for professionals, patients and carers (Chaklader 2012). Professionals need to work together to ensure the risks and benefits of eating and drinking are considered for each individual person to optimise their quality of life. This co-ordinated approach, particularly towards the end of life, is essential for patients with chronic progressive conditions, to ensure consistent and smooth transfer of care between acute and community settings (BGS 2012).

ANH may be inappropriate if:

  • The risk of the procedure outweighs the benefit.
  • The patient themselves declines ANH or has a valid advance directive.
  • The patient has poor prognosis/life expectancy.
  • The patient has advanced dementia. There is little evidence that ANH will improve quality of life or prolong life in advanced dementia (Royal College of Physicians 2010).

‘Comfort’ or ‘risk’ feeding are terms used to describe continuation of careful hand feeding when ANH is not appropriate, while acknowledging there are risks in doing so (e.g. aspiration), and minimising these risks as much as possible. It is generally accepted that such patients will be in the palliative stage of their care. Palliative care is defined as “the active holistic care of patients with advanced illness” (NICE 2004). The goal of palliative care is to achieve the best quality of life for patients and their families and for many patients this phase is the last year of a person’s life, not just the last weeks and days. In Buckinghamshire Healthcare NHS Trust (BHT) this is supported with a Palliative Care Plan which allows for planning and support so that people have more choice about their care during their last months and can make decisions about their preferred place of death. Thus, this document and the accompanying plan will be known as “Palliative Feeding for Comfort”. Although the food and drink provided may not fully meet the nutritional/hydration needs of the patient, it is intended to provide comfort and an overall feeling of wellbeing. Typically, prescribed nutritional products are unlikely to be indicated when someone is nearing the end of his or her life.