Home Parenteral Nutrition for Patients with Bowel Obstruction
Inoperable Malignant
DAVID A. AUGUST, M.D.,* DEBORAH THORN, M.B.A.,† ROSEMARIE L. FISHER, M.D.,‡ CYNTHIA M. WELCHEK, B.S.† From the
AND
and ‡Internal Medicine, Yale University School of Medicine, and the Nutrition Yale-New Haven Hospital, New Haven, Connecticut
Departments of *Surgery, tPharmacy,
plication requiring readmission occurred. Fourteen patients and their families (82%) perceived their therapy as highly beneficial or beneficial. The NST agreed with this assessment in 11 patients but did not share this perception in three patients. These three patients had a short duration of HPN (less than 25 days) or minimal rehabilitation. It is concluded that HPN for patients with IMBO is associated with a low complication rate, may be most beneficial for those patients with gastrointestinal tract primary tumors, and is usually perceived by patients and care providers as beneficial. HPN has palliative benefit and facilitates compassionate home care for carefully selected patients with IMBO. ( Journal of Parenteral and Enteral Nutrition 15 :323-327, 1991)
ABSTRACT. The use of home parenteral nutrition (HPN) in patients with inoperable malignant bowel obstruction (IMBO) is controversial. The efficacy, safety, and indications for HPN in these patients is uncertain, and its benefit is difficult to demonstrate. The records of 17 patients (9, ovarian cancer; 4, colon cancer; 4, other) with IMBO receiving HPN managed by the Nutrition Support Team (NST) at Yale-New Haven Hos-
pital from 1980 to 1989 were reviewed. Median survival was 53 days and was longest in the two patients with appendiceal carcinomatosis (208 and 159 days), intermediate in patients with colon cancer (median 90 days), and shortest in patients with ovarian cancer (median 39 days). Survival was unrelated to age or sex. All patients died of their underlying disease; 82% of deaths occurred at home. Only one treatment-related com-
Malignant neoplasm is the most common indication for the use of home parenteral nutrition (HPN) in the United States. An increasing number of cancer patients receiving HPN is terminally ill and unable to maintain adequate fluid and nutrient intake because of inoperable malignant bowel obstruction (IMBO). They are dependent on intravenous fluid to prevent dehydration, and parenteral nutritional support to prevent starvation. As is true with any therapy, the use of HPN in the setting of IMBO is predicated on the expectation of demonstrable benefit for the patient. In the presence of an incurable malignancy, such benefit is by definition palliative. This palliation may take the form of prolongation of life or improvement in the quality of life. As summarized by the American Society for Parenteral and Enteral Nutrition Board of Directors, HPN &dquo;in patients with an extremely poor prognosis and no hope for improvement evokes very difficult ethical issues and should not be undertaken without full discussion with the patient and appropriate family members. In general, little benefit is observed.&dquo;’ Nevertheless, some authors have reported the beneficial use of HPN in cancer patients with gastrointestinal dysfunction precluding enteral nutrition.3-’ Miller and Ivey,’ conversely, concluded that HPN &dquo;appears to be of extremely limited benefit in patients with ’untreatable’ malignancies.&dquo; The current Reprints to: David A. August, M.D., University of Michigan, Department of Surgery, Division of Surgical Oncology, 1500 East Medical Center Drive, TC 2920-0331, Ann Arbor. MI 48109.
Support Team,
study was undertaken to review the Yale-New Haven Hospital experience with the use of HPN in patients with IMBO to obtain further data regarding the efficacy, safety, and indications for HPN in this patient population. Also assessed was the benefit of this therapy as perceived by the patients, their care providers, and the Nutrition Support Team (NST). PATIENTS AND METHODS
Clinical records of the NST were reviewed to identify all patients discharged from Yale-New Haven Hospital on HPN and diagnosed as having IMBO between 1980 and 1989. These records along with information obtained from hospital records and discussions with care providers were analyzed to determine patient age and sex, location of the primary cancer, TPN formula and administration regimen, duration of HPN therapy, length of survival after discharge on HPN, reasons for readmission following discharge on HPN, and cause of death. NST records were reviewed to form an impression of the patient and family perception of the value of HPN therapy and the quality of life it afforded. These records contain extensive progress notes that include information regarding subjective as well as objective measures of the outcome of HPN therapy. The NST care providers’ perception of these factors was similarlv determined from Team records and from discussion with the involved care providers. Patient and family perception and NST (by at least two independent observers) perception of value of therapy were rated independently as 0 1 not beneficial l, 1
323 Downloaded from pen.sagepub.com at LAKEHEAD UNIV on March 14, 2015
324 TABLE I
(beneficial), and 2 (highly beneficial) based on length of survival; rehabilitation status; ease of management of therapy by patient, family, and home health care providers ; nature of home life, and frequency and intensity of clinical intervention by the NST. While these criteria are highly subjective, by nature quality of life assessments are observer-dependent. In general, therapy was rated not beneficial when either the patient or family stated such, when survival was less than 30 days, or when survival was less than 40 above was problematic.
Results
days and any other factor listed * Median
(range). TABLE II Value of therapy
RESULTS
From January 1, 1980, until June 1, 1989, 65 patients cared for by the NST were discharged on HPN. Seventeen of these HPN patients (26%) had IMBO that prevented adequate enteral fluid and nutrient intake (Table I). Thirteen patients were women and four were men. Their median age was 58 years (range 33-79 years). The ovaries were the site of the primary cancer in nine patients, the colon in four, the appendix in two, the endometrium in one, and the stomach in one. Because of intractable vomiting resulting from the bowel obstruction, six patients had a gastrostomy tube placed before
discharge For
seven
a
by site of primary cancer
permit gastrointestinal (GI) tract drainage. patients, GI drainage was provided by a na-
to
sogastric tube. The HPN regimen consisted of 1.0 to 3.0 L of a crystalline amino acid (4.25 or 5.0%) and dextrose (2535%) mixture compounded with appropriate electrolytes, vitamins, and minerals administered through a long-term venous access device. Lipid emulsion (250 ml of a 20% solution) was given to most patients weekly. The regimen was individually designed for each patient to meet assessed protein, calorie, and fluid requirements while avoiding metabolic complications. Survival data were calculated from the day of first discharge on HPN (Table I). The median survival of all patients was 53 days (range 5-208 days). Median survival was shortest in those patients with ovarian and endometrial primaries (39 and 51 days, respectively), intermediate in those with colonic primaries (89 days), and longest in those patients with other gastrointestinal primaries (159 days). Only four patients with ovarian cancer (44%) survived longer than 40 days, whereas three patients with colon cancer (75%), the patient with stomach cancer, the patient with endometrial cancer, and both patients with cancer of the appendix survived longer than 40 days. When assessed independently of the primary site of the tumor, age and sex did not correlate with postdischarge survival. Following discharge, three patients were readmitted to evaluate complications possibly related to HPN. Three febrile episodes developed in two patients; they were readmitted for evaluation. In no instance was the HPN solution or the venous access catheter implicated as the source of the fever. The third patient was readmitted because her venous access catheter dislodged. It was removed, but cancer progression precluded reinstitution of HPN prior to death. All metabolic derangements that arose as a result of bowel obstruction, disease progres-
* Value of therapy as perceived by the patient and family and by the NST (0, not beneficial; 1, beneficial; 2, highly beneficial).
sion, or the HPN were managed at home without adverse sequelae. In all patients, HPN was continued to within 4 days of death. Tumor progression was the cause of death in all patients. Fourteen of the 17 patients (82%) died at home. The perceived value of HPN therapy as assessed by the patient and family and by the NST was independently rated as 0 (not beneficial), 1 (beneficial), and 2 (highly beneficial) from information contained in NST records (Table II). For 11 patients all agreed the HPN was beneficial or highly beneficial. In three patients the therapy was not beneficial. Of these three patients, one’s venous access catheter became dislodged 1 day following discharge. She was readmitted, and died 4 days later. One survived only 15 days on HPN; she was quite uncomfortable and was &dquo;a burden&dquo; to her family. The third patient survived for 94 days on HPN, but he suffered from increasing debilitation and pain. In three instances the patient and family rated HPN beneficial or highly beneficial, but the NST rated the therapy as not beneficial. In two patients the lack of rehabilitation and mobility as well as the burden placed on the families were felt by the NST to outweigh any benefits of the therapy. The third patient survived 10 days on HPN and was able to get married in this short period of time. Both she and her family thus felt the therapy was highly beneficial. Because of the short duration of therapy and the recognition that intravenous fluid therapy could have achieved equivalent palliation,
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325
the NST felt that the HPN therapy was not of benefit. In only one of the 11 patients who survived longer than 40 days did the patient and family perceive no benefit in the therapy; in two of these 11 patients the NST rated the therapy not beneficial.
were alive at 77 and 150 days. Neither of these reports commented upon the adequacy of enteral nutrient intake in these patients nor the extent to which malnutrition may have contributed to mortality. The data presented concern the use of HPN in patients with IMBO in whom surgical resection or bypass was
patients
feasible, strictly pharmacologic palliation was not adequate, and enteral intake was minimal. HPN should only be considered when these other measures have failed and when survival beyond 40 days is probable. The 17 patients described herein were unable to enterally support their daily fluid requirements. Thirteen required gastric drainage because vomiting and crampy abdominal pain could not be palliated pharmacologically. Early in the series, uncertainty regarding the indications for application of this therapy resulted in its utilization in some patients with a very limited prognosis. During this study, an important criterion that was developed to select patients with IMBO for HPN is estimated survival of greater than 40 days. This is used in an effort to identify those patients who will benefit from nutritional support as opposed to simple parenteral hydration. Calculated acute starvation-depletion times to 50% loss of lean body mass (a figure generally thought to be incompatible with life), which have been partially validated by the experiences of self-imposed hunger strikers, suggest that acute starvation in previously healthy fasters leads to death in 60 to 70 days. 12 Similar calculations accounting for the preexisting cancer cachexia and nitrogen catabolism experienced by patients with IMBO imply that the time to death from starvation is closer to 35 to 40 days in this group. Since 1986, 80% of the IMBO patients discharged by the NST from Yale-New Haven Hospital on HPN indeed survived longer than 40 days (us 47% prior to 1986). Miller and Ivey6 described three patients in whom HPN was utilized to palliate IMBO. No treatment-related complications were noted. Survival was approximately 3 months, 2 months, and 1 week. Of the nine patients reported by Weiss et al,’ four had chronic bowel obstruction. The complications observed were primarily catheter-related, and survival ranged from 2 weeks to 3 months. Three patients with IMBO treated with HPN were reported by Moley et al.‘~ Complications requiring readmission were limited to a single episode of catheter sepsis. The patients survived 24 months, 6 months, and 1.5 months following discharge. The largest series to date was reported by Cartmill and colleagues.’ They managed 25 patients with IMBO using HPN. Survival at home ranged from 1 week to 13 months (mean 84 days). Gouttebel et all reported the use of HPN in eight &dquo;terminally ill&dquo; cancer patients. Survival ranged from 1 to 6 months and morbidity was quite low. In the present series, median survival following discharge was 53 days, and 100 days in those with nonovarian primary tumors. A 58year-old man with metastatic carcinoma of the appendix survived 208 days. There was onlv one treatment-related complication and no HPN-related mortality. An attempt was made to assess the palliative benefit of HPN for patients with I1MB0, since it is safe and offers to some patients the potential of prolonged surnot
DISCUSSION
The role of parenteral nutrition in the support of with cancer remains uncertain 20 years after the first clinical trials of total parenteral nutrition (TPN)~ and almost 15 years since the earliest description of the use of TPN in patients with malignancies.’ Reviews have emphasized the appropriateness of the therapeutic use of TPN for malnourished cancer patients receiving anticancer therapy.9-14 TPN can induce positive nitrogen balance and weight gain in cancer patients.13,15 The role of adjuvant parenteral nutrition in the patient with cancer is much less certain.&dquo; Some authors report improved response rates and fewer side effects of chemotherapy, although others have noted no benefit in patients supported with TPN.1° There is far less information regarding the efficacy, safety, and appropriateness of utilizing TPN within a home setting for terminally ill patients with incurable cancers. Given the technical ability to administer such therapy, questions must be asked regarding its efficacy, safety, and impact. HPN is only appropriate for those patients &dquo;who are unable to meet their nutritional requirements by the oral or enteral route for a prolonged period of time. If oral nutrient intake is inadequate, every effort should be made to use the enteral route ... before HPN is deemed necessary.&dquo;2 The vast majority of patients with malignant bowel obstruction can be managed without the use of HPN. Osteen et all and Walsh and Schofield18 have emphasized the appropriateness of laparotomy in patients with previously treated malignancies presenting with bowel obstruction. The cause of the obstruction is frequently not tumor related, and many patients with malignant bowel obstruction are able to undergo successful tumor resection or bypass for palliation. For those patients in whom operative resection or bypass is inappropriate or impossible, aggressive medical management may alleviate the abdominal pain, vomiting, and dehydration that result from IMBO. Aggressive utilization of
patients
narcotics, anticholinergics, antiemetics, phenothiazines, butyrophenones, and tricyclic antidepressants may palliate malignant bowel obstruction. Baines et all9 described 38 patients who were treated in this fashion with a mean survival of almost 4 months; seven patients survived for more than 7 months. The authors concluded that the distressing symptoms of IMBO can often be controlled pharmacologically. An alternative approach that has been described is the use of a venting gastrostomy in conjunction with either enteral&dquo; or parenteral2l fluids. In the study of Gemlo et al, 21 when venting gastrostomy was supplemented by intravenous hydration with a 10% dextrose-containing saline solution, mean duration of survival was approximately 64 days. Malone et al2l utilized only enteral support ; in the seven patients who had died at the time of reporting, mean survival was 35 days (26-56 days). Three
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326 vival. Nutritional support in and of itself is not antineo-
plastic. Thus, its efficacy depends on whether it lengthens survival or improves quality of life. The observation that patients who would otherwise die of dehydration or starvation can survive on HPN longer than 40 days suggests that HPN may permit prolonged survival in some carefully selected patients with IMBO. To assess the quality-of-life palliation afforded by this therapy, the patient and family perception of the value of HPN was determined. In patients, who survived 5
days and one who survived 15 days, it can be said retrospectively that they were poor candidates for HPN. They were bedridden and suffered from chronic pain. In only one patient who survived longer than 40 days was the therapy perceived as not beneficial by the patient and family, because of constant depression, uncontrollable pain, and inability of the patient to provide any self-care. Only in this patient might HPN have contributed to prolongation of suffering. In three additional patients, the NST felt that the therapy provided little benefit. Two of these patients survived 10 and 22 days, and the NST felt that parenteral fluid therapy would have afforded similar quality-of-life palliation at a lower cost and in a simpler fashion. An ovarian cancer patient who survived for 77 days and who viewed her therapy as beneficial spent 55 days hospitalized suffering from dyspnea and depression. She perceived the benefit of the therapy to be related to her husband’s desire to have her live as long as possible. The NST felt this provided little direct benefit to the patient. In the remaining cases, the patients, their families, and the NST all perceived the HPN as providing substantial improvement in quality of life. Patients were able to spend time outside of the hospital. Fourteen of 17 patients in this series were able to die at home with their families in attendance in familiar surroundings. Most authors concur that, in carefully selected patients, HPN can offer palliation of IMBO.3-5,23 Miller and Ivey6 disagree, but their series included one patient who did not have IMBO.~ Of their three other patients, one was able to return to work and was offered additional time to allow him and his wife to better adjust to his
impending death. The reason that patients with primary ovarian tumors seemed to be afforded poorer palliation by HPN in the present series is not obvious, but may relate to overall tumor burden. While the ovarian cancer patients were generally younger, they also tended to have bulkier intraabdominal disease. Their tumor burden may have imposed a greater physiologic insult, thus limiting the palliation offered by a therapy directed only at the mechanical effects of tumors on their GI tracts. This series does not comment on the cost of HPN in patients with IMBO. From prior experiences,4°5 it is evident that, if palliative therapy is undertaken in these patients, it is cheaper to do so in an outpatient setting. When considering the use of HPN in patients with IMBO, it must be understood that HPN requires the active participation of the patient, the patient’s family, and the patient’s primary physician. Support of an HPN program requires the involvement of knowledgeable phy-
nurses, pharmacists, dietitians, social workers, discharge planners, home care nurses, and home care vendors. In the present experience, HPN in patients with IMBO is very labor intensive. It requires extensive home nursing support and frequent NST intervention by telephone or through outpatient visits to avoid serious complications, to provide emotional support to the patient and family, and to optimize palliation and quality of life. Despite its clear cost saving when compared with inpatient therapy, the expense of HPN is nevertheless substantial. While third-party payers are becoming increasingly enlightened, there are still many instances where insurance coverage is inadequate to provide the range of vendor and nursing support necessary to undertake HPN. To avoid a crippling financial burden to the patient and family, it is important to verify adequate insurance coverage or to develop alternative means of payment. In this regard, social workers and discharge planners play a crucial role in the evaluation of these patients. Few patients would think of their therapy as beneficial if they knew it would result in a crippling financial situation for their families following their
sicians,
death. It is concluded that HPN can be safely administered to patients with IMBO. This therapy should be offered only when other modes of treatment including surgical relief of obstruction, intensive medical management, and outpatient fluid therapy have been deemed ineffective or inappropriate. Only those patients with a strong commitment to this therapy and with families who will support this substantial undertaking should be offered this alternative. Additional selection criteria should include an estimated length of survival longer than 40 days and the availability of personnel and financial resources to support the home care effort. Location of the primary tumor may also predict the degree of palliation achievable. Within these guidelines, HPN for patients with IMBO is practical, safe, and compassionate. REFERENCES 1.
Oley/A.S.P.E.N. Information System (OASIS): Home nutritional support patient registry: Annual report, 1986 data. Oley Foundation, Albany, NY, 1988
2. A.S.P.E.N. Board of Directors: Guidelines for use of home total parenteral nutrition. JPEN 11:342-344, 1987 3. Moley JF, August DA, Norton JA, et al: Home parenteral nutrition
4. 5. 6. 7.
for patients with advanced intraperitoneal cancers and gastrointestinal dysfunction. J Surg Oncol 33:186-189, 1986 Weiss SM, Worthington PH, Prioleau M, et al: Home parenteral nutrition in cancer patients. Cancer 50:1210-1213, 1982 Cartmill A, Manning L, Gilsdorf RB: Home total parenteral nutrition for patients with terminal cancer (abstr). JPEN 11:13S, 1987 Miller DG, Ivey MF: Use of home parenteral nutrition in four patients with "untreatable" malignancies. JPEN 3:457-458, 1979 Dudrick SJ, Wilmore DW, Vars HM, et al: Can intravenous feeding as the sole means of nutrition support growth in the child and restore weight loss in an adult? An affirmative answer. Ann Surg
169:974-984, 1969 BV Jr, Dudrick SJ: Intravenous hyperalimentation in cancer patients. J Surg Res 16:241-247, 1974 9. Copeland EM: Intravenous hyperalimentation and cancer. A historical perspective. JPEN 10:337-342, 1986 10. Fischer JE: Adjuvant parenteral nutrition in the patient with cancer. Surgery 96:578-580, 1984 8.
Copeland EM, Macfayden
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327 11. Brennan MF: Total parenteral nutrition in the cancer patient. N Engl J Med 305:375-382, 1981 12. A.S.P.E.N. Board of Directors: Guidelines for the use of total parenteral nutrition in the hospitalized adult patient. JPEN
10:441-445, 1986 13. Souba
WW, Copeland
EM:
Hyperalimentation
in
cancer.
CA
39:105-114, 1989 14. Gouttebel MC, Saint-Aubert B, Jonquet O, et al: Ambulatory home parenteral nutrition. JPEN 11:475-479, 1987 15. Bozzetti F, Ammatuna M, Migliavacca S, et al: Total parenteral nutrition prevents further nutritional deterioration in patients with cancer cachexia. Ann Surg 205:138-143, 1987
College of Physicians: Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110:734-735, 1989 17. Osteen RT, Guyton S, Steele G Jr, et al: Malignant intestinal obstruction. Surgery 87:611-615, 1980 18. Walsh HPJ, Schofield PF: Is laparotomy for small bowel obstruc-
tion 19.
20.
21.
22.
16. American
23.
justified in patients with previously treated malignancy? Br J Surg 71:933-935, 1984 Baines M, Oliver DJ, Carter RI: Medical management of intestinal obstruction in patients with advanced malignant disease: A clinical and pathological study. Lancet 2:990-993, 1985 Malone JM, Koonce T, Larson DM, et al: Palliation of small bowel obstruction by percutaneous gastrostomy in patients with progressive ovarian carcinoma. Obstet Gynecol 68:431-433, 1986 Gemlo B, Rayner AA, Lewis B, et al: Home support of patients with end-stage malignant bowel obstruction using hydration and venting gastrostomy. Am J Surg 152:100-104, 1986 Shike M, Brennan MF: Supportive care of the cancer patient: Nutritional support. IN Cancer: Principles and Practice of Oncology, 3rd ed, DeVita VT Jr, Hellman S, Rosenberg SA (eds). Lippincott, Philadelphia, 1989, pp 2029-2044 Stokes MA, Almond DJ, Pettit SH, et al: Home parenteral nutrition: A review of 100 patient years of treatment in 76 consecutive cases. Br J Surg 75:481-483, 1988
Downloaded from pen.sagepub.com at LAKEHEAD UNIV on March 14, 2015
Inoperable Malignant
DAVID A. AUGUST, M.D.,* DEBORAH THORN, M.B.A.,† ROSEMARIE L. FISHER, M.D.,‡ CYNTHIA M. WELCHEK, B.S.† From the
AND
and ‡Internal Medicine, Yale University School of Medicine, and the Nutrition Yale-New Haven Hospital, New Haven, Connecticut
Departments of *Surgery, tPharmacy,
plication requiring readmission occurred. Fourteen patients and their families (82%) perceived their therapy as highly beneficial or beneficial. The NST agreed with this assessment in 11 patients but did not share this perception in three patients. These three patients had a short duration of HPN (less than 25 days) or minimal rehabilitation. It is concluded that HPN for patients with IMBO is associated with a low complication rate, may be most beneficial for those patients with gastrointestinal tract primary tumors, and is usually perceived by patients and care providers as beneficial. HPN has palliative benefit and facilitates compassionate home care for carefully selected patients with IMBO. ( Journal of Parenteral and Enteral Nutrition 15 :323-327, 1991)
ABSTRACT. The use of home parenteral nutrition (HPN) in patients with inoperable malignant bowel obstruction (IMBO) is controversial. The efficacy, safety, and indications for HPN in these patients is uncertain, and its benefit is difficult to demonstrate. The records of 17 patients (9, ovarian cancer; 4, colon cancer; 4, other) with IMBO receiving HPN managed by the Nutrition Support Team (NST) at Yale-New Haven Hos-
pital from 1980 to 1989 were reviewed. Median survival was 53 days and was longest in the two patients with appendiceal carcinomatosis (208 and 159 days), intermediate in patients with colon cancer (median 90 days), and shortest in patients with ovarian cancer (median 39 days). Survival was unrelated to age or sex. All patients died of their underlying disease; 82% of deaths occurred at home. Only one treatment-related com-
Malignant neoplasm is the most common indication for the use of home parenteral nutrition (HPN) in the United States. An increasing number of cancer patients receiving HPN is terminally ill and unable to maintain adequate fluid and nutrient intake because of inoperable malignant bowel obstruction (IMBO). They are dependent on intravenous fluid to prevent dehydration, and parenteral nutritional support to prevent starvation. As is true with any therapy, the use of HPN in the setting of IMBO is predicated on the expectation of demonstrable benefit for the patient. In the presence of an incurable malignancy, such benefit is by definition palliative. This palliation may take the form of prolongation of life or improvement in the quality of life. As summarized by the American Society for Parenteral and Enteral Nutrition Board of Directors, HPN &dquo;in patients with an extremely poor prognosis and no hope for improvement evokes very difficult ethical issues and should not be undertaken without full discussion with the patient and appropriate family members. In general, little benefit is observed.&dquo;’ Nevertheless, some authors have reported the beneficial use of HPN in cancer patients with gastrointestinal dysfunction precluding enteral nutrition.3-’ Miller and Ivey,’ conversely, concluded that HPN &dquo;appears to be of extremely limited benefit in patients with ’untreatable’ malignancies.&dquo; The current Reprints to: David A. August, M.D., University of Michigan, Department of Surgery, Division of Surgical Oncology, 1500 East Medical Center Drive, TC 2920-0331, Ann Arbor. MI 48109.
Support Team,
study was undertaken to review the Yale-New Haven Hospital experience with the use of HPN in patients with IMBO to obtain further data regarding the efficacy, safety, and indications for HPN in this patient population. Also assessed was the benefit of this therapy as perceived by the patients, their care providers, and the Nutrition Support Team (NST). PATIENTS AND METHODS
Clinical records of the NST were reviewed to identify all patients discharged from Yale-New Haven Hospital on HPN and diagnosed as having IMBO between 1980 and 1989. These records along with information obtained from hospital records and discussions with care providers were analyzed to determine patient age and sex, location of the primary cancer, TPN formula and administration regimen, duration of HPN therapy, length of survival after discharge on HPN, reasons for readmission following discharge on HPN, and cause of death. NST records were reviewed to form an impression of the patient and family perception of the value of HPN therapy and the quality of life it afforded. These records contain extensive progress notes that include information regarding subjective as well as objective measures of the outcome of HPN therapy. The NST care providers’ perception of these factors was similarlv determined from Team records and from discussion with the involved care providers. Patient and family perception and NST (by at least two independent observers) perception of value of therapy were rated independently as 0 1 not beneficial l, 1
323 Downloaded from pen.sagepub.com at LAKEHEAD UNIV on March 14, 2015
324 TABLE I
(beneficial), and 2 (highly beneficial) based on length of survival; rehabilitation status; ease of management of therapy by patient, family, and home health care providers ; nature of home life, and frequency and intensity of clinical intervention by the NST. While these criteria are highly subjective, by nature quality of life assessments are observer-dependent. In general, therapy was rated not beneficial when either the patient or family stated such, when survival was less than 30 days, or when survival was less than 40 above was problematic.
Results
days and any other factor listed * Median
(range). TABLE II Value of therapy
RESULTS
From January 1, 1980, until June 1, 1989, 65 patients cared for by the NST were discharged on HPN. Seventeen of these HPN patients (26%) had IMBO that prevented adequate enteral fluid and nutrient intake (Table I). Thirteen patients were women and four were men. Their median age was 58 years (range 33-79 years). The ovaries were the site of the primary cancer in nine patients, the colon in four, the appendix in two, the endometrium in one, and the stomach in one. Because of intractable vomiting resulting from the bowel obstruction, six patients had a gastrostomy tube placed before
discharge For
seven
a
by site of primary cancer
permit gastrointestinal (GI) tract drainage. patients, GI drainage was provided by a na-
to
sogastric tube. The HPN regimen consisted of 1.0 to 3.0 L of a crystalline amino acid (4.25 or 5.0%) and dextrose (2535%) mixture compounded with appropriate electrolytes, vitamins, and minerals administered through a long-term venous access device. Lipid emulsion (250 ml of a 20% solution) was given to most patients weekly. The regimen was individually designed for each patient to meet assessed protein, calorie, and fluid requirements while avoiding metabolic complications. Survival data were calculated from the day of first discharge on HPN (Table I). The median survival of all patients was 53 days (range 5-208 days). Median survival was shortest in those patients with ovarian and endometrial primaries (39 and 51 days, respectively), intermediate in those with colonic primaries (89 days), and longest in those patients with other gastrointestinal primaries (159 days). Only four patients with ovarian cancer (44%) survived longer than 40 days, whereas three patients with colon cancer (75%), the patient with stomach cancer, the patient with endometrial cancer, and both patients with cancer of the appendix survived longer than 40 days. When assessed independently of the primary site of the tumor, age and sex did not correlate with postdischarge survival. Following discharge, three patients were readmitted to evaluate complications possibly related to HPN. Three febrile episodes developed in two patients; they were readmitted for evaluation. In no instance was the HPN solution or the venous access catheter implicated as the source of the fever. The third patient was readmitted because her venous access catheter dislodged. It was removed, but cancer progression precluded reinstitution of HPN prior to death. All metabolic derangements that arose as a result of bowel obstruction, disease progres-
* Value of therapy as perceived by the patient and family and by the NST (0, not beneficial; 1, beneficial; 2, highly beneficial).
sion, or the HPN were managed at home without adverse sequelae. In all patients, HPN was continued to within 4 days of death. Tumor progression was the cause of death in all patients. Fourteen of the 17 patients (82%) died at home. The perceived value of HPN therapy as assessed by the patient and family and by the NST was independently rated as 0 (not beneficial), 1 (beneficial), and 2 (highly beneficial) from information contained in NST records (Table II). For 11 patients all agreed the HPN was beneficial or highly beneficial. In three patients the therapy was not beneficial. Of these three patients, one’s venous access catheter became dislodged 1 day following discharge. She was readmitted, and died 4 days later. One survived only 15 days on HPN; she was quite uncomfortable and was &dquo;a burden&dquo; to her family. The third patient survived for 94 days on HPN, but he suffered from increasing debilitation and pain. In three instances the patient and family rated HPN beneficial or highly beneficial, but the NST rated the therapy as not beneficial. In two patients the lack of rehabilitation and mobility as well as the burden placed on the families were felt by the NST to outweigh any benefits of the therapy. The third patient survived 10 days on HPN and was able to get married in this short period of time. Both she and her family thus felt the therapy was highly beneficial. Because of the short duration of therapy and the recognition that intravenous fluid therapy could have achieved equivalent palliation,
Downloaded from pen.sagepub.com at LAKEHEAD UNIV on March 14, 2015
325
the NST felt that the HPN therapy was not of benefit. In only one of the 11 patients who survived longer than 40 days did the patient and family perceive no benefit in the therapy; in two of these 11 patients the NST rated the therapy not beneficial.
were alive at 77 and 150 days. Neither of these reports commented upon the adequacy of enteral nutrient intake in these patients nor the extent to which malnutrition may have contributed to mortality. The data presented concern the use of HPN in patients with IMBO in whom surgical resection or bypass was
patients
feasible, strictly pharmacologic palliation was not adequate, and enteral intake was minimal. HPN should only be considered when these other measures have failed and when survival beyond 40 days is probable. The 17 patients described herein were unable to enterally support their daily fluid requirements. Thirteen required gastric drainage because vomiting and crampy abdominal pain could not be palliated pharmacologically. Early in the series, uncertainty regarding the indications for application of this therapy resulted in its utilization in some patients with a very limited prognosis. During this study, an important criterion that was developed to select patients with IMBO for HPN is estimated survival of greater than 40 days. This is used in an effort to identify those patients who will benefit from nutritional support as opposed to simple parenteral hydration. Calculated acute starvation-depletion times to 50% loss of lean body mass (a figure generally thought to be incompatible with life), which have been partially validated by the experiences of self-imposed hunger strikers, suggest that acute starvation in previously healthy fasters leads to death in 60 to 70 days. 12 Similar calculations accounting for the preexisting cancer cachexia and nitrogen catabolism experienced by patients with IMBO imply that the time to death from starvation is closer to 35 to 40 days in this group. Since 1986, 80% of the IMBO patients discharged by the NST from Yale-New Haven Hospital on HPN indeed survived longer than 40 days (us 47% prior to 1986). Miller and Ivey6 described three patients in whom HPN was utilized to palliate IMBO. No treatment-related complications were noted. Survival was approximately 3 months, 2 months, and 1 week. Of the nine patients reported by Weiss et al,’ four had chronic bowel obstruction. The complications observed were primarily catheter-related, and survival ranged from 2 weeks to 3 months. Three patients with IMBO treated with HPN were reported by Moley et al.‘~ Complications requiring readmission were limited to a single episode of catheter sepsis. The patients survived 24 months, 6 months, and 1.5 months following discharge. The largest series to date was reported by Cartmill and colleagues.’ They managed 25 patients with IMBO using HPN. Survival at home ranged from 1 week to 13 months (mean 84 days). Gouttebel et all reported the use of HPN in eight &dquo;terminally ill&dquo; cancer patients. Survival ranged from 1 to 6 months and morbidity was quite low. In the present series, median survival following discharge was 53 days, and 100 days in those with nonovarian primary tumors. A 58year-old man with metastatic carcinoma of the appendix survived 208 days. There was onlv one treatment-related complication and no HPN-related mortality. An attempt was made to assess the palliative benefit of HPN for patients with I1MB0, since it is safe and offers to some patients the potential of prolonged surnot
DISCUSSION
The role of parenteral nutrition in the support of with cancer remains uncertain 20 years after the first clinical trials of total parenteral nutrition (TPN)~ and almost 15 years since the earliest description of the use of TPN in patients with malignancies.’ Reviews have emphasized the appropriateness of the therapeutic use of TPN for malnourished cancer patients receiving anticancer therapy.9-14 TPN can induce positive nitrogen balance and weight gain in cancer patients.13,15 The role of adjuvant parenteral nutrition in the patient with cancer is much less certain.&dquo; Some authors report improved response rates and fewer side effects of chemotherapy, although others have noted no benefit in patients supported with TPN.1° There is far less information regarding the efficacy, safety, and appropriateness of utilizing TPN within a home setting for terminally ill patients with incurable cancers. Given the technical ability to administer such therapy, questions must be asked regarding its efficacy, safety, and impact. HPN is only appropriate for those patients &dquo;who are unable to meet their nutritional requirements by the oral or enteral route for a prolonged period of time. If oral nutrient intake is inadequate, every effort should be made to use the enteral route ... before HPN is deemed necessary.&dquo;2 The vast majority of patients with malignant bowel obstruction can be managed without the use of HPN. Osteen et all and Walsh and Schofield18 have emphasized the appropriateness of laparotomy in patients with previously treated malignancies presenting with bowel obstruction. The cause of the obstruction is frequently not tumor related, and many patients with malignant bowel obstruction are able to undergo successful tumor resection or bypass for palliation. For those patients in whom operative resection or bypass is inappropriate or impossible, aggressive medical management may alleviate the abdominal pain, vomiting, and dehydration that result from IMBO. Aggressive utilization of
patients
narcotics, anticholinergics, antiemetics, phenothiazines, butyrophenones, and tricyclic antidepressants may palliate malignant bowel obstruction. Baines et all9 described 38 patients who were treated in this fashion with a mean survival of almost 4 months; seven patients survived for more than 7 months. The authors concluded that the distressing symptoms of IMBO can often be controlled pharmacologically. An alternative approach that has been described is the use of a venting gastrostomy in conjunction with either enteral&dquo; or parenteral2l fluids. In the study of Gemlo et al, 21 when venting gastrostomy was supplemented by intravenous hydration with a 10% dextrose-containing saline solution, mean duration of survival was approximately 64 days. Malone et al2l utilized only enteral support ; in the seven patients who had died at the time of reporting, mean survival was 35 days (26-56 days). Three
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326 vival. Nutritional support in and of itself is not antineo-
plastic. Thus, its efficacy depends on whether it lengthens survival or improves quality of life. The observation that patients who would otherwise die of dehydration or starvation can survive on HPN longer than 40 days suggests that HPN may permit prolonged survival in some carefully selected patients with IMBO. To assess the quality-of-life palliation afforded by this therapy, the patient and family perception of the value of HPN was determined. In patients, who survived 5
days and one who survived 15 days, it can be said retrospectively that they were poor candidates for HPN. They were bedridden and suffered from chronic pain. In only one patient who survived longer than 40 days was the therapy perceived as not beneficial by the patient and family, because of constant depression, uncontrollable pain, and inability of the patient to provide any self-care. Only in this patient might HPN have contributed to prolongation of suffering. In three additional patients, the NST felt that the therapy provided little benefit. Two of these patients survived 10 and 22 days, and the NST felt that parenteral fluid therapy would have afforded similar quality-of-life palliation at a lower cost and in a simpler fashion. An ovarian cancer patient who survived for 77 days and who viewed her therapy as beneficial spent 55 days hospitalized suffering from dyspnea and depression. She perceived the benefit of the therapy to be related to her husband’s desire to have her live as long as possible. The NST felt this provided little direct benefit to the patient. In the remaining cases, the patients, their families, and the NST all perceived the HPN as providing substantial improvement in quality of life. Patients were able to spend time outside of the hospital. Fourteen of 17 patients in this series were able to die at home with their families in attendance in familiar surroundings. Most authors concur that, in carefully selected patients, HPN can offer palliation of IMBO.3-5,23 Miller and Ivey6 disagree, but their series included one patient who did not have IMBO.~ Of their three other patients, one was able to return to work and was offered additional time to allow him and his wife to better adjust to his
impending death. The reason that patients with primary ovarian tumors seemed to be afforded poorer palliation by HPN in the present series is not obvious, but may relate to overall tumor burden. While the ovarian cancer patients were generally younger, they also tended to have bulkier intraabdominal disease. Their tumor burden may have imposed a greater physiologic insult, thus limiting the palliation offered by a therapy directed only at the mechanical effects of tumors on their GI tracts. This series does not comment on the cost of HPN in patients with IMBO. From prior experiences,4°5 it is evident that, if palliative therapy is undertaken in these patients, it is cheaper to do so in an outpatient setting. When considering the use of HPN in patients with IMBO, it must be understood that HPN requires the active participation of the patient, the patient’s family, and the patient’s primary physician. Support of an HPN program requires the involvement of knowledgeable phy-
nurses, pharmacists, dietitians, social workers, discharge planners, home care nurses, and home care vendors. In the present experience, HPN in patients with IMBO is very labor intensive. It requires extensive home nursing support and frequent NST intervention by telephone or through outpatient visits to avoid serious complications, to provide emotional support to the patient and family, and to optimize palliation and quality of life. Despite its clear cost saving when compared with inpatient therapy, the expense of HPN is nevertheless substantial. While third-party payers are becoming increasingly enlightened, there are still many instances where insurance coverage is inadequate to provide the range of vendor and nursing support necessary to undertake HPN. To avoid a crippling financial burden to the patient and family, it is important to verify adequate insurance coverage or to develop alternative means of payment. In this regard, social workers and discharge planners play a crucial role in the evaluation of these patients. Few patients would think of their therapy as beneficial if they knew it would result in a crippling financial situation for their families following their
sicians,
death. It is concluded that HPN can be safely administered to patients with IMBO. This therapy should be offered only when other modes of treatment including surgical relief of obstruction, intensive medical management, and outpatient fluid therapy have been deemed ineffective or inappropriate. Only those patients with a strong commitment to this therapy and with families who will support this substantial undertaking should be offered this alternative. Additional selection criteria should include an estimated length of survival longer than 40 days and the availability of personnel and financial resources to support the home care effort. Location of the primary tumor may also predict the degree of palliation achievable. Within these guidelines, HPN for patients with IMBO is practical, safe, and compassionate. REFERENCES 1.
Oley/A.S.P.E.N. Information System (OASIS): Home nutritional support patient registry: Annual report, 1986 data. Oley Foundation, Albany, NY, 1988
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for patients with advanced intraperitoneal cancers and gastrointestinal dysfunction. J Surg Oncol 33:186-189, 1986 Weiss SM, Worthington PH, Prioleau M, et al: Home parenteral nutrition in cancer patients. Cancer 50:1210-1213, 1982 Cartmill A, Manning L, Gilsdorf RB: Home total parenteral nutrition for patients with terminal cancer (abstr). JPEN 11:13S, 1987 Miller DG, Ivey MF: Use of home parenteral nutrition in four patients with "untreatable" malignancies. JPEN 3:457-458, 1979 Dudrick SJ, Wilmore DW, Vars HM, et al: Can intravenous feeding as the sole means of nutrition support growth in the child and restore weight loss in an adult? An affirmative answer. Ann Surg
169:974-984, 1969 BV Jr, Dudrick SJ: Intravenous hyperalimentation in cancer patients. J Surg Res 16:241-247, 1974 9. Copeland EM: Intravenous hyperalimentation and cancer. A historical perspective. JPEN 10:337-342, 1986 10. Fischer JE: Adjuvant parenteral nutrition in the patient with cancer. Surgery 96:578-580, 1984 8.
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39:105-114, 1989 14. Gouttebel MC, Saint-Aubert B, Jonquet O, et al: Ambulatory home parenteral nutrition. JPEN 11:475-479, 1987 15. Bozzetti F, Ammatuna M, Migliavacca S, et al: Total parenteral nutrition prevents further nutritional deterioration in patients with cancer cachexia. Ann Surg 205:138-143, 1987
College of Physicians: Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110:734-735, 1989 17. Osteen RT, Guyton S, Steele G Jr, et al: Malignant intestinal obstruction. Surgery 87:611-615, 1980 18. Walsh HPJ, Schofield PF: Is laparotomy for small bowel obstruc-
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justified in patients with previously treated malignancy? Br J Surg 71:933-935, 1984 Baines M, Oliver DJ, Carter RI: Medical management of intestinal obstruction in patients with advanced malignant disease: A clinical and pathological study. Lancet 2:990-993, 1985 Malone JM, Koonce T, Larson DM, et al: Palliation of small bowel obstruction by percutaneous gastrostomy in patients with progressive ovarian carcinoma. Obstet Gynecol 68:431-433, 1986 Gemlo B, Rayner AA, Lewis B, et al: Home support of patients with end-stage malignant bowel obstruction using hydration and venting gastrostomy. Am J Surg 152:100-104, 1986 Shike M, Brennan MF: Supportive care of the cancer patient: Nutritional support. IN Cancer: Principles and Practice of Oncology, 3rd ed, DeVita VT Jr, Hellman S, Rosenberg SA (eds). Lippincott, Philadelphia, 1989, pp 2029-2044 Stokes MA, Almond DJ, Pettit SH, et al: Home parenteral nutrition: A review of 100 patient years of treatment in 76 consecutive cases. Br J Surg 75:481-483, 1988
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