Medically assisted nutrition for adult palliative care patients Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract Background

Many palliative care patients have a reduced oral intake during their illness. The management of this can include the provision of medically assisted nutrition with the aim of prolonging the length of life of a patient, improving their quality of life, or both. This is an updated version of the original Cochrane review published in Issue 4, 2008.

Objectives

To determine the effect of medically assisted nutrition on the quality and length of life of palliative care patients.

Search methods

We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible trials, key textbooks and previous systematic reviews. The date of the latest search was 26 March 2014.

Selection criteria

All relevant randomised controlled trials (RCTs) or prospective controlled trials (if no RCTs were found).

Data collection and analysis

We found no RCTs or prospectively controlled trials that met the inclusion criteria.

Main results

The original review identified four prospective non‐controlled trials and the updated search in 2014 identified one more (plus an updated version of a Cochrane review on enteral feeding in motor neuron disease). There were five prospective non‐controlled trials (including one qualitative study) that studied medically assisted nutrition in palliative care participants, and one Cochrane systematic review (on motor neuron disease that found no RCTs), but no RCTs or prospective controlled studies.

Authors' conclusions

Since the last version of this review, we found no new studies. There are insufficient good‐quality trials to make any recommendations for practice with regards to the use of medically assisted nutrition in palliative care patients.

Author(s)

Phillip Good, Russell Richard, William Syrmis, Sue Jenkins‐Marsh, Jane Stephens

Abstract

Plain language summary

Medically assisted nutrition to assist palliative care patients

Background

It is common for palliative care patients to have reduced oral intake during their illness. Management of this condition includes discussion with the patient, family and staff involved, and may include giving nutrition with medical assistance. This can be done either via a plastic tube inserted directly into a vein or into the stomach or other parts of the gastrointestinal tract. It is unknown whether this treatment helps people to feel better or live longer.

Study characteristics

We searched the international literature for randomised controlled trials looking at the effects of medically assisted nutrition in adults receiving palliative care. Randomised controlled trials allocate patients to one of two or more treatment groups in a random manner and provide the most accurate information on the best treatment. The search was conducted in April 2013 and March 2014.

Key results

We found no randomised controlled trials. As a result, it is not possible to define the benefits and harms of this treatment clearly.

Author(s)

Phillip Good, Russell Richard, William Syrmis, Sue Jenkins‐Marsh, Jane Stephens

Reviewer's Conclusions

Authors' conclusions

Implications for practice

Since the last version of this review, we found no new studies. There are insufficient good‐quality studies to make any recommendations for practice with regards to the use of medically assisted nutrition in palliative care patients. Clinicians will need to make a decision based on the perceived benefits and harms of medically assisted nutrition in individual patient circumstances, without the benefit of high‐quality evidence to guide them. The uncontrolled prospective studies described would suggest that patients with a good performance status and medium‐ to long‐term prognosis (months to years) may benefit from medically assisted nutrition. However, the evidence base to support this at the moment is weak and any intention to use this treatment should be monitored carefully and ideally fed in to further research.

Implications for research Trial design

There are very few quality studies that have examined medically assisted nutrition in palliative care patients. It may be difficult to perform an RCT in this area. The logistics of recruiting participants to any palliative care trial are well known (Rinck 1997), but are especially so with regards to medically assisted nutrition. Further trials of the effect of medically assisted nutrition would be useful in two distinct palliative care populations. The first is patients who develop the anorexia/cachexia syndrome. The second is in patients who are unable to swallow, but whose prognosis (from their cancer/illness, e.g. motor neuron disease) would seem to be longer than their prognosis from the aphagia. The difficulty in this situation is the reliance on the physician's ability to provide a prognosis, and this is not always accurate (Glare 2003).

As well as looking at the possibility of RCTs in this area, the evidence base will be improved with at least some prospective controlled trials, and even with more prospective uncontrolled trials. This may need innovative designs such as comparisons between different centres that have different nutrition practices or by following up cohorts of participants who are offered medically assisted nutrition, in whom some proceed and some do not (as long as the two groups are similar).

Patient groups

The studies in this review did not have well‐defined patient populations. Palliative care is performed in hospital, inpatient palliative care units and the community. Trials need to be performed in all these areas to allow external validity (able to be applied to a similar patients as those seen in a trial) to different palliative care populations. It would also be helpful to define at what stage of their illness participants are being given medically assisted nutrition. The reasons and aims of nutrition in the last few days/weeks of life may be very different to those of participants with a longer prognosis. The prospective prediction of prognosis is difficult, and it may be better to stratify participants according to performance status.

Interventions

Medically administered nutrition can be given by many different routes. Further trials are needed to determine the optimum route and dose.

Outcomes

It is important that clinically relevant outcomes are clearly defined and are the most clinically useful to this situation. In this patient population, this includes energy levels, functional status and overall quality of life. As well as these, the effect of this intervention on overall survival needs to be reported. It is also important that the adverse events are well defined so that the risk of treatment can be balanced against any benefits.

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