Because of requirements for increased calorie intake in aged care facilities, today it’s common to find dietary supplements, such as those you’d find on a supermarket shelf, on the trays of residents. We need to be careful about this.
Is the supplement replacing real food with texture and flavour?
Is it providing calories to someone who is not able to benefit from them?
“Many people find that they do not feel like eating near the end-of-life. Dietary supplements have a limited role in this situation, and indeed in nutrition in general. When a person does not want to eat and drink for whatever reason, then a supplement may very well not help as it may also be unwanted,” said Dr Wroth.
And there are particular circumstances that need to be considered individually.
For example, an 81-year-old woman newly diagnosed with a terminal oesophageal cancer should have choices about whether she wants or doesn’t want percutaneous endoscopic gastrostomy (PEG), a feeding tube, when her disease advances.
Having choices outlined in Advance Care Directives
Some people, given this option, will want the extra time it gives. Others will say no. The person’s attitude towards this should be clearly outlined in an updated advance care directive. Ideally, this elderly lady will lead this discussion with those who are important to her, those she defines as family including one or two people who she nominates as the ‘persons responsible’ if she can no longer speak for herself.
In Australia, if an elderly person with a terminal condition in an aged care facility chooses not to eat or drink they are now not forced to. The reasons have to be considered carefully and efforts made to determine what’s behind the decision. If the elderly person remains committed to this, their carers need to ensure they have access to medications so they are not in discomfort or pain and that they can access food and water readily if they change their mind.
Feeding is part of the advance care planning discussion. So, some aged care facility advance care directives invite residents to tick yes or no to levels of feeding. For example:
Oral or Basic: Food and fluids by mouth, helped to eat and drink. No food via a tube or intravenous line (drip) into veins.
Supplementary: Oral + additives for the patient’s requirements. May include additional vitamins and high energy drinks.
Intravenous (IV): Supplemental + fluids and nutritional supplements given through a vein.
Tube: IV + a tube into the stomach through the nose (nasogastric tube) or a tube which goes through the skin into the stomach (gastrostomy tube.)
Some residents and families presented with such options tick yes to all of the above, without realising the implications these will have for prolonging life artificially.
If you are the resident or the person responsible for someone in an aged care facility, you have the right to discuss all options until you feel completely satisfied with the information you have been given.
It’s important that people are helped to eat and drink, until they clearly say ‘no’ and that they are not stopping because of an artificial barrier, such as staff not having the time to feed them.
Royal Commission
In Australia, from October 1 this year, and in response to the recommendations of the Royal Commission, a mandatory 200 minutes of care is required per day for residents of aged care facilities. This includes time spent feeding residents or cutting up their food, if they can’t do so themselves. Hopefully, this will result in improved feeding and therefore nutrition in those places where these have been undervalued.
Dehydration
As a separate issue, we need to be aware of hydration in the elderly. Yes, those at the end-of-life stop drinking. But maintaining access to drinking water is very important for those not at that stage.
“Dehydration amongst aged care residents is a common and dangerous problem,” the Aged Care Quality Commission says on its website at “Why do Meals Matter?”. This points to the problem of some aged care facility residents limiting their water intake so they don’t need to urinate much – an outcome of calling out for help to go to the toilet but not getting that help or the toileting routine being simplified with continence pads rather than trips to the toilet, much to the humiliation of residents.
And close to death we need to be aware of checking on the situation. If the dying person wants to drink – even tiny sips – water needs to be offered. Advice may be needed about this, since the loss of the swallow reflex could cause aspiration of water into the lungs. Sometimes fluid thickeners are used in this situation.
And when water can no longer be absorbed, offering ice blocks and mouth care, including ensuring the mouth is clean and moist, even the use of sprays can be useful to keep the dying person comfortable.
The role of supplements is Part 3 of the three part series, Feeding at the end-of-life.
Read Part 1: The feeding needs of people at the end-of-life here and Part 2: Malnutrition in the elderly here
Resources
To explore more about feeding at the end of life and the data that has informed today’s decision making, see the following article which is based on an extensive review of a number of studies. National Clinical Guideline Centre (UK). Care of Dying Adults in the Last Days of Life. London: National Institute for Health and Care Excellence (NICE); 2015 Dec 16. (NICE Guideline, No. 31.) 8, Maintaining hydration. Available from: https://www.ncbi.nlm.nih.gov/books/NBK356009/
See also To PEG or Not To PEG, by William M Plonk, Jr. Nutrition Issues in Gastroenterology, Series no 29. https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/PlonkArticle-july2005.pdf
To read the Victorian study that found 68 per cent of elderly Australian participants were undernourished, go to: Iuliano, S., et al., Dairy food supplementation may reduce malnutrition risk in The British journal of nutrition, 2017. 117(1): p. 142-147. Published online 2017 Jan 18. doi: 10.1017/S000711451600461X
For any questions about food and diet in an aged care facility, ring the Food, Nutrition and Dining Hotline on 1800 844 044.
To see the National Aged Care Mandatory Quality Program Quick Reference Guide: Unplanned Weight Loss, go to: www.health.gov.au/sites/default/files/2023-03/qi-program-quick-reference-guide-unplanned-weight-loss.pdf
To read about the 200 care minutes requirement introduced for Australian aged care facilities on October 1, 2023, go to the Australian Government’s Care minutes and 24/7 registered nurse responsibility guide. https://www.health.gov.au/sites/default/files/2023-10/care-minutes-and-24-7-registered-nurse-responsibility-guide.pdf
For a statement to Good Grief! By Dr Melanie Wroth, Chief Clinical Advisor Aged Care Quality and Safety Commission addressing feeding at the end-of-life, go to: https://good-grief.com.au/statement-by-dr-melanie-wroth/
To read the Aged Care Quality and Safety Commission’s Why do meals matter? Go to:
https://www.agedcarequality.gov.au/providers/quality-care-resources/why-do-meals-matter
Food refusal has been discussed before by Good Grief! See:
https://good-grief.com.au/tag/do-we-have-the-right-to-refuse-food-food-refusal/
Read Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures, and the Patient with a Serious Illness : Book by Hank Dunn
© Margaret Rice