Patient Care Exam 1: Death and Dying, Nutrition in The Oncology Patient

What is disease-specific survival?

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The percentage of people in a study or treatment group who have not died from a specific disease in a defined period of time.

What is relative survival?

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a net survival measure representing cancer survival in the absence of other causes of death.

What is overall survival?

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The length of time from either the date of diagnosis or the start of treatment that patients diagnosed with the disease are still alive.

What is disease-free survival (progression-free survival [PFS])?

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the length of time after primary treatment for a cancer ends, that the patient survives without any signs or symptoms of that cancer.

What is the difference between cure and remission in cancer treatment?

Cure means no traces of cancer remain, while remission means signs and symptoms are reduced, which can be partial or complete.

How long must a patient be in remission to be considered cured by some physicians?

Some physicians consider a patient cured if they are in remission for 5 years or more.

What is the estimated number of Americans expected to die of cancer in 2025?

Over 618,120 Americans.

What are the consequences of failing to plan for end of life care?

Consequences include increased psychological distress, inconsistent medical treatments, ineffective use of healthcare resources, and difficult bereavement for families.

Why is it important to have early discussions about end of life care?

Early discussions can ease the transition into end of life care and ensure treatments align with patient wishes.

Patients continue to receive pricey treatments which might not be beneficial if they are near EOL

What is an Advanced Directive?

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An Advanced Directive is a legal document that outlines how medical decisions should be made if a person cannot make them themselves.

What are the types of Advanced Directives?

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Types include Medical Power of Attorney, Directive to Physicians (Living Will), and Out of Hospital Do Not Resuscitate (OOH-DNR).

What does a Medical Power of Attorney do?

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It names an individual who can make medical decisions on behalf of someone unable to do so.

What is the purpose of a Directive to Physicians (Living Will)?

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It allows individuals to state their wishes about medical care when they can no longer make decisions.

What is Out of Hospital Do Not Resuscitate (OOH-DNR)?

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a medical order that instructs healthcare providers, such as emergency medical services (EMS), not to perform cardiopulmonary resuscitation (CPR)

What is the focus of hospice care?

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Hospice focuses on quality of life for individuals with advanced, life-limiting illnesses, typically expected to die within 6 months.

How does palliative care differ from hospice care?

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Palliative care can be provided at any stage of a serious illness, while hospice is for patients in the last phase of an incurable illness.

What is the goal of palliative care?

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The goal is pain control and symptom management while the patient is still undergoing treatment.

What services does hospice provide?

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Hospice provides various services for both the patient and family, focusing on comfort and support.

What types of professionals provide hospice care?

Physicians, APPs, nursing staff, clinical aids, chaplains, social workers, and volunteers.

What is the availability of hospice care services?

Care is available 24/7 with nurses and physicians on call at all times.

What is respite care in the context of hospice services?

Respite care is temporary relief for primary caregivers, allowing them to take a break while ensuring the patient is cared for.

What is the significance of bereavement care in hospice?

Bereavement care and counseling are crucial for families after a patient passes away, providing support and services during their grieving process.

What is the importance of addressing spiritual concerns in end of life care?

Addressing spiritual concerns early can reduce the likelihood of patients requesting aggressive end of life measures.

What are common physical changes at the end of life?

Symptoms can vary but may include fatigue, pain, appetite changes, and breathing changes.

What is a common symptom experienced by oncology patients at the end of life?

Fatigue is one of the most common symptoms, often exacerbated by pain, nausea, and other factors.

How can caregivers help manage fatigue in patients?

Encourage a balance of rest and activity, and provide assistive devices to help with mobility.

What are some signs that a patient may be experiencing pain at the end of life?

Signs include noisy breathing, pained sounds, facial expressions of distress, and tense body language.

What changes in appetite are common at the end of life?

Patients may eat less due to taste/smell changes, nausea, and decreased energy, leading to weight loss.

What breathing changes might occur as death approaches?

Patients may experience shortness of breath, labored breathing, and may require oxygen or medications to relieve symptoms.

What are some signs of nearing death?

Signs include profound weakness, less interest in food/drink, difficulty swallowing, drowsiness, and confusion.

What changes in consciousness might be observed in patients nearing death?

Increased sleeping, difficulty waking, confusion mixed with clarity, and heightened anxiety or restlessness.

What changes in circulation can indicate approaching death?

Coolness in extremities, mottled skin, irregular heart rate, and potential loss of bowel/bladder control.

What sensory changes may occur as death approaches?

Vision and hearing may change; patients may have difficulty closing eyelids but can often still hear.

What is Cheyne-Stokes respiration?

A pattern of breathing characterized by cycles of deep, sometimes faster breathing followed by gradual decrease and temporary apnea.

Malnutrition definition

lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat.

Significant weight loss is thought to be

an indicator for increased incidence/severity of side effects, increased risk of infection, therefore worsening prognosis.

Anorexia definition

loss of appetite or desire to eat

Cachexia definition

progressive wasting syndrome usually presenting as weakness and significant, progressive loss of body weight, fat, and muscle (more often a side effect)

What tumors can increase risk of cachexia

GI tract tumors

Sarcopenia definition

severe muscle depletion

Malnutrition

According to the Oxford Dictionary, malnutrition is the lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat

what are the 3 types of malnutrition?

. Starvation-related—pure chronic starvation.

. Chronic disease-related malnutrition.

. Acute disease-related or injury-related.

what is an example of starvation-related—pure chronic starvation

anorexia nervosa

what are some examples of Chronic disease-related malnutrition.

organ failure, pancreatic cancer.

what are some examples of Acute disease-related or injury-related malnutrition

infection, major burns, closed head injury, trauma.

what are 6 potential indicators of malnutrition?

Insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized/generalized fluid accumulation (may mask weight loss), and decreased functional status (measured by hand grip strength)

if significant weight loss is present........

is thought to be an indicator for increased incidence/severity of side effects, increased risk of infection, therefore worsening prognosis.

Anorexia

is defined as the loss of appetite or desire to eat.

what percent of cancer patients present with anorexia at diagnosis?

15-25%

Anorexia can.....

. also occur as a side effect of treatment or secondary to the tumor itself

. be worsened due to chemotherapy or radiotherapy due to taste changes, nausea, and vomiting

. be worsened by anxiety and depression and lead to malnutrition

cachexia

. is a progressive wasting syndrome usually presenting as weakness and significant, progressive loss of body weight, fat, and muscle.

what can increase the risk of cachexia?

GI tract tumors

sarcopenia

is defined as severe muscle depletion

Some studies have shown that patients with ______ skeletal muscle index at diagnosis have potentially ________ prognosis

lower; worse

Studies have also shown ________ overall survival and _______ toxicity from chemotherapy in patients with sarcopenia.

poorer; increased

Sarcopenia is thought to occur in _____% of patients with advanced stage cancer and can cause......

. 50%

. treatment interruptions, dose reductions, and increased side effects

For many patients, unintentional weight loss is present _______ to their cancer diagnosis

PRIOR

It is imperative that we address the topic of.......

nutrition as early as possibly during their journey to hopefully minimize the chance of malnutrition.

Side effects that can contribute to nutrition include:

. Changes in taste and smell

. Mucositis, stomatitis, esophagitis

. Dysphagia

. Nausea/vomiting

. Diarrhea, constipation, malabsorption

. Pain

. Depression and anxiety

Nutrition goals:

01: maintain weight

02: maintain the ability to stay on intended treatment regimen with fewer treatment interruptions and dose reductions

03: improve quality of life

Baseline nutrition status:

What did the patient's nutrition look like when they first came to the hospital/clinic?

What Influences Nutrition Status and Risk of Malnutrition?

. Baseline nutrition status

. Disease site

. Stage of disease

. Proposed treatment plan (surgery, chemo, rad therapy)

As part of the RTT team, we need to know which patients may be at risk for ........

malnutrition secondary to their tumor location and treatment site

We most often see nutritional complications with tumors that originate in the _________________ or ________________

digestive tract; head and neck

Radiation-Induced Effects on Nutrition Status Typically begin around weeks ________ of treatment and __________ weeks following completion and can sometimes be __________

2-3; lessen 2-3; chronic

sometimes, the tumor can cause alterations in metabolism (cachexia). Typically seen in solid tumors of the ........

. lung, pancreas, and upper GI tract

. Not often seen in breast or lower GI cancers

. More common in advanced disease

Three stages of cachexia:

. Pre-cachexia

. Cachexia

. Refractory cachexia

Pre-cachexia:

early signs that precede significant weight loss

Cachexia: ( in terms of the second stage of cachexia)

. presence of significant weight loss or sarcopenia in the absence of simple starvation

. Weight loss >5% over the past 6 months; or

. Body mass index

. Sarcopenia and any degree of weight loss

Refractory cachexia:

clinically refractory, usually associated with advanced-stage cancer or rapid progression of disease that is unresponsive to treatment.

what are the multiple ways to screen for nutrition in patients?

. MST (Malnutrition Screening Tool)

. PG-SGA (Patient-Generated Subjective Global Assessment)

MST (Malnutrition Screening Tool):

. simple 2 question that puts patients into 2 categories—at risk or not at risk.

1) "Have you lost weight recently without trying?"

2) "Have you been eating poorly due to a decreased appetite?"

PG-SGA (Patient-Generated Subjective Global Assessment):

. 4 Sections with 17 data points

. Asks the patient about weight history, food intake, symptoms, and activities/function

. Patient is able to complete the assessment although is longer than the MST.

. Provider then completes a physical assessment section detailing what/if intervention is needed.

Nutrition therapy goals:

. Address current cancer and treatment related issues

. Minimize treatment side effects

. Anticipate any delayed or late side effects that may affect nutrition

For nutrition therapy, you must......

individualize to each patient depending on their diagnosis, treatment, and current nutritional status

Oncology Dietician:

. can provide individualized plans for your patients

. utilize research and evidence-based nutrition practices to work with the patient and family about nutrition and how to meet the patient's goals

. also collaborate with the medical team so that nutritional treatment plan aligns with the patient's medical treatment plan

Nutritional Supplements:

are always an option for patients to consider during their treatment

Examples: Boost, Ensure, Carnation Instant Breakfast

Nutritional supplements should not be..........

patients' sole source of nutrition!

. Find foods that are easier to eat that are high in calories and protein

Oral Hydration

. Recommend AT LEAST 64 ounces of non-caffeinated fluids during waking hours (UNLESS patient requires a fluid restriction due to renal or cardiac function).

. Patients should try to drink these throughout the day and not just in 1 or 2 sittings

. Sip on fluids throughout the day, limit during meals

Dehydration can make the patient feel......

MUCH worse

examples of hydrating fluids:

. Water

. Clear juices

. Sports drinks

. Broths

. Smoothies

. Protein shakes

. Teas—limit caffeine

Helpful to get an idea of caloric needs based on patients.......

age, gender, height, weight, and activity level.

Simple calculator:

25-30 kcals/kg/day

If patient is losing weight, _________ caloric intake

increase

Protein recommendations:

. 1 gram of protein per kg of body weight.

. May need to adjust based on amount of weight loss

Good sources of proteins:

. Lean animal proteins

. Green, leafy vegetables

. Legumes

. Nuts

. Beans

some patients, specifically _____________ patients, may require nutritional support via a _____________ ( enteral nutrition)

head and neck; PEG tube

why is a PEG tube the preferred method of nutritional support for head and neck patients?

It is the preferred method as it continues to use the gut with less infection complications

Other patients may require nutritional support via _____________ of nutrients (parenteral nutrition)

intravenous infusion

what patients may require nutritional support via intravenous infusion?

patients with a malfunctioning GI tract, malabsorption, or obstructions

PEG Tube:

A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube

Feeding tubes, or PEG tubes, allow you to.......

receive nutrition through your stomach

A patient may need a PEG tube if they have......

difficulty swallowing or can't get all the nutrition they need by mouth.

Nutritional Support is typically only indicated as a ......

supplement to treatment

Aggressive nutrition support isn't recommended if life expectancy is shorter than ___________

40-60 days

the criteria for withholding nutrition support in patients with advanced disease:

. Short estimated life expectancy (fewer than 2-3 months)

. Poor performance status (KPS

Karnofsky Performance Scale- KPS:

a scale that measures the neurologic and functional status of an individual; allows measuring of the quantity and quality of neurologic defects; ranges from 0 to 100

A 100 on the KPS means.........

Normal, no complaints, no evidence of disease

A 50 on the KPS means........

requires considerable assistance and frequence medical care

A 0 on the KPS means.......

Dead