Nutrition and hydration for terminal cancer patients in Taiwan

Many medical professionals are still confused when facing the reduction of food or fluid intake in terminal cancer patients. The aim of this study was to assess the frequency and causes of the inability of eating or drinking in terminal cancer patients and to investigate the use of artificial nutrition and hydration (ANH); the frequency, type, and the extent to which staff found ANH to be ethically justified. Three hundred forty-four consecutive patients with terminal cancer admitted to a palliative care unit in Taiwan were recruited. A structured data collection form was used daily to evaluate clinical conditions, which were analyzed at the time of admission, 1 week after admission and 48 h before death. One hundred thirty-three (38.7%) of the 344 patients were unable to take water or food orally on admission; the leading cause was GI tract disturbances (58.6%). This impaired ability to eat or drink had become worse 1 week after admission (39.1%, P<0.01) and again 48 h before death (60.1%, P<0.001). The total rate of ANH use declined significantly, from 57.0% to 46.9% 1 week after admission ( P<0.001), but rose again to the same level as at admission in the 48 h before death (53.1%, P=0.169). Parenteral hydratation could be reduced significantly 1 week after admission ( P<0.05), but no reduction was possible in the 48 h before death; nor was it possible to reduce the nutrition administered. Multiple Cox regression analysis shows that the administration of ANH, either at admission or 2 days before death, did not have any significant influence on the patients' survival (HR: 0.88, 95% CI: 0.58-1.07; HR: 1.03, 95% CI: 0.76-1.38). In conclusion, sensitive care and continuous communication will probably lessen the use of ANH in terminal cancer patients. We have found it easier to reduce artificial hydratation than artificial nutrition, which corresponds to local cultural practice. Whether or not ANH was used did not influence survival in this study. Thus, the goals of care for terminal cancer patients should be refocused on the promotion of quality of life and preparation for death, rather than in simply making every effort to improve the status of hydratation and nutrition.