NUTRITION MANAGEMENT IN

PALLIATIVE CARE

PENATALAKSANAAN NUTRISI PADA

PERAWATAN PALIATIF
SURYANI ASAD

2 nd MAKASSAR ANNUAL MEETING ON CLINICAL NUTRITION & PDGKI

NATIONAL CONGRESS
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
24-26 April 2015

LAPORAN
KASUS
NUTRITION
MANAGEMENT
IN PALLIATIVE CARE
I.INTRODUCTION
II.PALLIATIVE CARE
III.NUTRITION MANAGEMENT
LapSus 1

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
illnesswhatever the diagnosis. The goal of
such therapy is to improve quality of life for
both the patient and the family

PALLIATIVE CARE
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 and
spiritual.

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 of
dying)
- APPROACH TO PATIENS AND FAMILY
- ETHICAL PRINCIPLES
- NUTRITION INTERVENTION
- NUTRITION CHALLENGES

Approach to patients/families
NUTRITION CARE
Restore function
Prolong life

Comfort always

ETHICAL PRINCIPLES
Autonomy
Beneficence
Non-maleficence
Informed consent
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 MANAGEMENT

sUBYEKTIF
OBJEKTIF
ASSEssment
planning

STEPS IN
NUTRITION MANAGEMENT

stabilisaTiON
transiTiON
rehabilitaTiON

6 LANGKAH PENTING
1.
2.
3.
4.
5.
6.

MENGATASI DAN MENCEGAH HIPOGLIKEMIA

MENGATASI DAN MENCEGAH HIPOTERMIA
MENCEGAH DAN MENGATASI DEHIDRASI
KOREKSI GANGGUAN ELEKTROLIT
KOREKSI DEFISIENSI ZAT GIZI MIKRO
LAKUKAN STIMULASI SENSORIK DAN
DUKUNGAN EMOSI/MENTAL

Challenges in NUTRITION
MANAGEMENT PC
Failure to achieve balance
1. Decreased intake
Anorexia, xerostomia, altered
taste/smell, odyno/dysphagia

2. Decreased absorption
3. Altered energy utilization

Decreased intake
Anorexia (loss of appetite)
Multi-factorial
Cytokines: central (hypothalamic)
and peripheral (via vagus nerve)
influences
Huge frustration for families, source
of much tension

Approach in anorexia
1. Symptom control (nausea, pain)
2. Meal selection, timing,
portion/presentation
3. Avoid/reduce conflict (eat, drink, be
merry): eat what, where, when, as
much/little as you want
4. Natural resources

Pharmacology 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
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

Decreased absorption

Nausea
Emesis
Diarrhea
Surgical/anatomical changes

Altered energy metabolism

Algoritma Metode Pemberian Nutrisi

Role of Artificial Nutrition

Ethical Principles
Autonomy
Beneficence
Non-maleficence
Informed consent
Beauchamp and Childress. Principles of Biomedical Ethics. New York:
Oxford University Press. 1994 (4th Ed.)

ARTIFICIAL HYDRATION - NUTRITION

Artificial hydration and nutrition can provide people
with fluids and foods when they are no longer able to
eat or drink.
Includes intravenous (IV) fluids, tube feeding, and IV
nutrition (Total Parenteral Nutrition - TPN)
Artificial hydration and nutrition is not necessary to
provide comfort in the last stages of life.
It may actually make a person more uncomfortable by
contributing to shortness of breath, swelling, vomiting,
diarrhea, and cramps. Artificial hydration and nutrition
will 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. CONCLUSION
NUTRITION MANAGEMENT IN
PALLIATIVE CARE
IMPORTANT
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)

IV. Cachexia versus Starvation

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

Thomas, D. Distinguishing Starvation from Cachexia. Clinics in

Geriatric Medicine. 2002; 18: 883-891

Cachexia versus Starvation

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 status
or illness severity?
Acute-phase cytokine response
Strong inverse correlation between IL-2R and
albumin, pre-albumin, cholesterol, Hgb
Thomas, D. Distinguishing Starvation from Cachexia. Clinics in
CommonGeriatric
pathway
to2002;
reduction
Medicine.
18: 883-891 in albumin, etc.
may be cytokine induction, rather than absence
of nutrients