Frías-Toral E.Rev. Nutr. Clin. Metab. 2021;4(2):1-3.





The role of nutrition in palliative care


El rol de la nutrición en los cuidados paliativos

O papel da nutrição nos cuidados paliativos


Evelyn Frías-Toral, MD, MSc*

https://doi.org/10.35454/rncm.v4n2.275



*Corresponding author: Evelyn Frías Toral.

evelyn.frias@cu.ucsg.edu.ec


Collaborating for more than a decade in the Society for the Fight against Cancer (SOLCA), the cancer hospital of primary reference in Ecuador, allowed me to deeply value the positive impact of providing timely and adequate palliative care (PC) to these patients. This Ecuadorian institution was the first to meet the growing demand for these specialized services. Comprehensive management of nutritional aspects positively affects both the disease’s evolution and these patients’ quality of life (QoL). For that reason, it was necessary to propose to the distinguished editor of “Revista de Nutrición Clínica y Metabolismo”, a highly prestigious journal for scientific dissemination, this thematic issue to present the harmonious work of these two specialties in the management of patients with incurable diseases, in an advanced stage, out of therapeutic resources, and terminal stage.

After consensus, the International Association for Hospice & Palliative Care (IAHPC) redefined PCs in 2020 as “Active, holistic care for people of all ages with serious health-related suffering (SHS) due to serious illness and disease, especially of those nearing the end of life. It aims to improve the QoL of patients, their families and their caregivers”(1).

Nutritional evaluation and intervention constitute the fundamental pillars in patients who benefit from PC. Since they directly fall into the domain identified by the National Coalition for Hospice and Palliative Care-National Consensus Project, related to the management of symptoms, among which are weight loss, weakness, and fatigue(2). Additionally, the exponential growth of pediatric and adult patients with PC requirements due to SHS encompasses a variety of diseases and conditions such as congenital anomalies, neonatal conditions, heart failure, progressive neurological diseases, chronic kidney disease, advanced liver disease, chronic obstructive pulmonary disease, AIDS, diabetes, cancer, among others(3, 4).

Worldwide, it is estimated that 40 million people require PC, 50 % in the terminal stage. It is noteworthy that promoting the early implementation of PC in conjunction with precise nutritional interventions in these diseases can reduce the number of hospital admissions and improve these patients’ QoL(5-7). All of these must be analyzed in detail by a multidisciplinary team that estimates each patient’s risks and benefits. Furthermore, these recommendations must be aligned with ethical principles and respect for the patient and family’s wishes concerning their therapeutic strategies(8).

It is essential to highlight that the Cartagena Declaration (DC), whose main objective is to promote nutritional care and fight against malnutrition(9), covers the unique nutritional requirements for this particular group of patients in several of its principles. The latter is very common in these patients who sometimes reach their end early due to some complications related to their nutritional status or management rather than their underlying condition. It is essential to feed the PC patient with dignity with comprehensive recommendations that respect the patient’s autonomy (DC principle 1, 5). Nutritional care implies a systematic process based on a multidisciplinary approach that considers each PC user’s preferences (DC principles 2-4). As presented by several authors in this special issue, there is a need for more scientific evidence that promotes the implementation of nutritional guidelines in PC patients at the regional and international level, which entails a joint work of the professionals involved in the management of these patients (DC principles 7, 9, 13).

For the points aforementioned, in this thematic issue, regional and international opinion leaders, representatives of the different specialties involved in PC (Clinical Nutrition, Bioethics, Internal Medicine, Surgery, Oncology, Pediatrics, Psychology, Nursing, among others) will present updated information based on evidence and accumulated experience throughout their practice, attending to the specific needs of this especially vulnerable group of patients. Thus, this issue’s objective is to disseminate the importance of early adoption of PCs in conjunction with timely nutritional evaluation and treatment for SHS patients’ comprehensive management.

Due to the increasing request for PCs globally, the first article in this special issue discusses PCs’ basics. Santacruz et al. present the definition of PC, its historical development, and the role of nutrition in PC(10). The President of the Latin American PC Association, Patricia Bonilla, describes PCs’ progress in Latin America concerning the following domains: education, availability of opioids, research, public policies, and service implementation(11). The professor and researcher, editor of the journal, Diana Cárdenas, in her review, answers two fundamental questions about PC When should nutritional therapy be started and when should it stop? Does nutritional therapy improve QoL and prolong PC patients’ survival?(12).

PCs have a profound impact on the patient’s autonomy, which is why professor Barrocas et al. lay out in detail the ethical perspectives of PC and nutrition. They describe the North American approach to successful PC interventions based on Respect, Communication, and Teamwork (ACT). They show the Cartagena Declaration’s relationship in the PCs to achieve patient-centered care. These concepts finally land in the specific management of patients with advanced dementia(13). ESPEN Early Career Faculty Giovanna Muscogiuri et al. summarize the general and specific ESPEN recommendations for the nutritional management of advanced stages of the primary diseases that benefit from PC(14). Vallejo et al. specified oral feeding patterns as a component of the CP therapeutic in cancer patients at end-stage disease(15). Sabogal et al. share the experience acquired in cancer patients’ nutritional treatment in advanced stages or with poor prognosis from the Hepatobiliary and Pancreatic Surgery Service of the Mederi Hospital in Colombia. His paper explains the approach used, based on a human emphasis with particular attention to strengthening the physician-patient relationship(16).

The Brazilian professor Zorzo et al. analyze the indications and contraindications of artificial hydration and nutrition in an even more vulnerable population, the pediatric group in PC. They highlight the importance of a thorough and continuous evaluation to determine the best nutritional treatment options in these patients. In this decision-making process, the relevance of a multidisciplinary care team’s joint participation, the patients and their families, is highlighted to reach this objective(17). The Uruguayan leaders of the ECHO project (Extension for Community Healthcare Outcomes) for Latin America in PC deepen the importance of the nutritional management of the patient, the comprehensive approach, and the impact on the emotional sphere, not only of the patient but of the family core(18). To conclude, in a practical way, Maza et al. feature the management of an advanced case of gastric adenocarcinoma with in-hospital parenteral nutrition. Also, it exposes the existing limitations in the region of having parenteral nutrition at home in favor of these patients(19).

Finally, I wish to express my special thanks to professors Dolores Rodríguez (Clinical Nutrition) and Mariana Vallejo (Palliative Care) for being excellent mentors and having motivated me to expand my clinical and research practice in this population with special requirements. My sincere wish is that this thematic issue promotes Nutritional Recommendations in Palliative Care and lays the foundations for future research in this area.


Conflict of interest


None to declare.



Evelyn Frías-Toral, MD, MSc

Physician and General Surgeon graduated at the Catholic University of Santiago de Guayaquil. Master in Clinical and Epidemiological Research from the University of Guayaquil with a Diploma in Enteral Nutrition and Applied Parenteral from the University of Montrer, Mexico. She is Associate Professor of Research Methodology at the Postgraduate Palliative Care at the Catholic University of Santiago de Guayaquil. She is part of the Scientific, Teaching and Publications Committee of ASENPE (Ecuadorian Association of Parenteral and Enteral Nutrition) and is its representative before the International Council of ESPEN (European Society of Clinical Nutrition and Metabolism). She has obtained several distinctions including being part of the first group of ESPEN Early Career Faculty which has allowed her to actively participate in several ESPEN projects, such as nutritionDay, among others. She is Associate Editor of the journals Clinical Nutrition ESPEN and Revista de Nutrición Clínica y Metabolismo.



References


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