MAMCN Suryani Nutrition Palliative Care

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NUTRITION M N GEMENT IN

P LLI TIVE C RE

PENATALAKSANAAN NUTRISI PADA

PERAWATAN PALIATIF

SURYANI AS’AD

2 nd MAKASSAR ANNUAL MEETING ON CLINICAL NUTRITION & PDGKINATIONAL CONGRESS

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

24-26 April 2015



2

LapSus 1

LAPORAN KASUS

NUTRITION MANAGEMENT

IN PALLIATIVE CARE

I.INTRODUCTION

II.PALLIATIVE CARE

III.NUTRITION MANAGEMENT

IV.CONCLUSION



I. INTRODUCTION

• PALLIATIVE : Latin “pallium”

• In 1990, WHO : TOTAL CARE

• 2005 : COMPREHENSIVE- INTEGRATIF –HOLISTIC CARE



Let food be your medicine and let

medicine be your food” Hippocrates



II. PALLIATIVE CARE

• Palliative care is a multidisciplinary approach

to specialised medical care for people with

serious illnesses. It focuses on providing

patients with relief from the symptoms, pain,

physical stress, and mental stress of a serious

illness—whatever the diagnosis. The goal of

such therapy is to improve quality of life forboth the patient and the family

http://en.wikipedia.org/wiki/Multidisciplinary_approach

http://en.wikipedia.org/wiki/Health_care

http://en.wikipedia.org/wiki/Disease

http://en.wikipedia.org/wiki/Symptom

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Stress_(biology)

http://en.wikipedia.org/wiki/Stress_(psychological)

http://en.wikipedia.org/wiki/Diagnosis

http://en.wikipedia.org/wiki/Therapy

http://en.wikipedia.org/wiki/Quality_of_life

http://en.wikipedia.org/wiki/Quality_of_life

http://en.wikipedia.org/wiki/Therapy

http://en.wikipedia.org/wiki/Diagnosis

http://en.wikipedia.org/wiki/Stress_(psychological)

http://en.wikipedia.org/wiki/Stress_(biology)

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Symptom

http://en.wikipedia.org/wiki/Disease

http://en.wikipedia.org/wiki/Health_care

http://en.wikipedia.org/wiki/Multidisciplinary_approach



• WHO definition:

– …improves quality of life of patients and their

families

– ……prevention and relief of suffering

– …..early identification,… assessment and

treatment of

– …. problems, physical, psychosocial andspiritual.

PALLIATIVE CARE



PALLIATIVE CARE IN INDONESIA

• START 19 February 1992, SOME HOSPITALS:

• Dr. Soetomo (Surabaya)

• Cipto Mangunkusumo (Jakarta)• Kanker Dharmais (Jakarta)

• Wahidin Sudirohusodo (Makassar)

• Sardjito (Yogyakarta)• Sanglah (Denpasar).



III. NUTRITION MANAGEMENT

GOALS OF CARE

(Maintain quality of life; avoid prolongation ofdying)

- APPROACH TO PATIENS AND FAMILY

- ETHICAL PRINCIPLES- NUTRITION INTERVENTION

- NUTRITION CHALLENGES



Approach to patients/families

Comfort always

Prolong life

Restore function

NUTRITION CARE



– Autonomy

– Beneficence

– Non-maleficence

– Informed consent

ETHICAL PRINCIPLES

Beauchamp and Childress. Principles of Biomedical Ethics. New York:Oxford University Press. 1994 (4th Ed.)



NUTRITION IN PALLIATIVE CARE

• HOSPITALIZE

• HOME CARE

• DAY CARE• RESPITE CARE



Nutrition M N GEMENT

sUBYEKTIF

O

BJEKTIF

SSEssment

planning



STEPS IN

NUTRITION M N GEMENT

stabilisaTiON

transiTiON

rehabilitaTiON



6 LANGKAH PENTING

1. MENGATASI DAN MENCEGAH HIPOGLIKEMIA

2. MENGATASI DAN MENCEGAH HIPOTERMIA

3. MENCEGAH DAN MENGATASI DEHIDRASI4. KOREKSI GANGGUAN ELEKTROLIT

5. KOREKSI DEFISIENSI ZAT GIZI MIKRO

6. LAKUKAN STIMULASI SENSORIK DANDUKUNGAN EMOSI/MENTAL



• Failure to achieve balance

1. Decreased intake

• Anorexia, xerostomia, alteredtaste/smell, odyno/dysphagia

2. Decreased absorption

3. Altered energy utilization

Challenges in NUTRITION

MANAGEMENT PC



• Anorexia (loss of appetite)

–Multi-factorial

–“Cytokines”: central (hypothalamic)and peripheral (via vagus nerve)

influences

–Huge frustration for families, source

of much tension

Decreased intake



1. Symptom control (nausea, pain)

2. Meal selection, timing,portion/presentation

3. Avoid/reduce conflict (eat, drink, be

merry): “eat what, where, when, asmuch/little as you want”

4. Natural resources

Approach in anorexia



Appetite stimulants (progestational agent:

megestrol) may increase intake , body

weight, and quality of life, but they do not

affect prognosis in the terminally ill

Pharmacology in anorexia

Dy, M. “Enteral and Parenteral Nutrition in

Terminally Ill Cancer Patients: a Review of the

Literature.” American Journal of Hospice and

Palliative Medicine. 2006; 23 (5): 369-377



• Nausea• Emesis

• Diarrhea

• Surgical/anatomical changes

Altered energy metabolism

Decreased absorption



Algoritma Metode Pemberian Nutrisi



• Ethical Principles

– Autonomy

– Beneficence

– Non-maleficence

– Informed consent

Role of Artificial Nutrition

Beauchamp and Childress. Principles of Biomedical Ethics. New York:Oxford University Press. 1994 (4th Ed.)



ARTIFICIAL HYDRATION - NUTRITION

• Artificial hydration and nutrition can provide peoplewith fluids and foods when they are no longer able toeat or drink.

• Includes intravenous (IV) fluids, tube feeding, and IVnutrition (Total Parenteral Nutrition - TPN)

• Artificial hydration and nutrition is not necessary toprovide comfort in the last stages of life.

• It may actually make a person more uncomfortable bycontributing to shortness of breath, swelling, vomiting,diarrhea, and cramps. Artificial hydration and nutritionwill not bring a person back to a healthy condition.



Acetylcholine (ACh): mengawasi aktivitas daerah

otak yang ada hubungannya dengan perhatian,

dan memori.

Glutamat : eksitator neurotransmitter otak yang

penting, vital untuk membentuk hubungan antar

neuron yang merupakan dasar dari memori jangka

panjang



IV. CONCLUSIONNUTRITION MANAGEMENT IN

PALLIATIVE CAREIMPORTANT

ETHICAL ASPECT





Nutrien yang sering digunakan

• Serat larut----mengikat HDL

• Folat---mengurangi homosistein

(a.a.berpotensi peny.jtg)• Omega-3, omega-9 (meningkatkan

imunitas, menurunkan LDL, meningkatkan

HDL)• Lemak tidak jenuh (monounsaturated fat)



Starvation Cachexia

Appetite Late suppression Early suppression

BMI Not predictive of mortality Predictive of mortality

Albumin Low in late phase Low in early phase

Cholesterol May remain normal Low

Total lymphocyte

count

Low, responds to

re-feeding

Low, no response to

re-feeding

Cytokines Little data Elevated

Inflammation Usually absent Present

With re-feeding Reversible Resistant

IV. Cachexia versus Starvation

Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in

Geriatric Medicine. 2002; 18: 883-891



Cachexia versus Starvation

Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in

Geriatric Medicine. 2002; 18: 883-891

• Starvation: pure protein/energy deficiency

(under-nutrition)

• Cachexia: cytokine-induced wasting of protein

and energy stores, caused by effects of disease

• Biochemical markers represent nutritional statusor illness severity?

• Acute-phase cytokine response

• Strong inverse correlation between IL-2R and

albumin, pre-albumin, cholesterol, Hgb

• Common pathway to reduction in albumin, etc.

may be cytokine induction, rather than absence

of nutrients

MAMCN Suryani Nutrition Palliative Care

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