Total parenteral nutrition (TPN) continues to be inappropriately used at the end of life in cancer patients, according to a review of home-based TPN reported by researchers from Moffitt Cancer Center in Tampa, Florida, at the 2013 Gastrointestinal Cancers Symposium.
“Our study of home TPN did not show a great outcome. In fact, the results were pretty dismal,” said Margaret Cass-Garcia, RN, MSN, CNSC. “The patients often are readmitted with the same symptoms they had when we started them on TPN.” TPN is increasingly used in terminally ill cancer patients with cachexia or bowel dysfunction, but the American College of Physicians discourages this practice. In addition to providing little benefit to the dying patient, the practice is costly: $15,000 to $18,000 a month for home TPN, according to the investigator.
The purpose of this retrospective study was to determine the validity of TPN in patients who were terminally ill from advanced gastrointestinal (GI) cancer, and to compare this group with patients with other malignancies.
The study focused on 89 patients treated at Moffitt Cancer Center who were receiving TPN in their own home between 2007 and 2012. All had stage IV cancer with a nonfunctional GI tract (two-thirds had bowel dysfunction) or failure to thrive (surgical patients were excluded), and were ineligible for surgery. Forty-four percent had palliative gastrostomy tubes.
Although they received TPN for the same duration, patients with GI cancer lived for a shorter time than did patients with other malignancies. Very few patients resumed eating, and these had primarily been started on TPN because of failure to thrive, not bowel obstruction.
TPN-related complications were common, with 74% of patients requiring readmission and many admitted several times. While some readmissions were related to the chemo- therapy that half the patients continued to receive, most admissions were in some way due to TPN-related conditions, in particular, lack of symptom resolution, she said.
Overall, 17 patients had restored bowel function, and only 1 patient was still alive at the time of the analysis.
"We recognize that there are subjective reasons for giving TPN to terminally ill cancer patients, and they include compassionate, ethical, religious, and emotional reasons,” Cass-Garcia acknowledged, “but essentially, your body has told you it doesn’t want to eat. TPN may be prolonging life or prolonging death, and there is a grey area. This is a hard conversation with the family.”
Reference Cass-Garcia M, Hodul PJ, Almhanna K. Use of total parenteral nutrition (TPN) in terminally ill gastrointestinal (GI) cancer patients (pts) compared to other malignancies (OM): a single-institution experience. Presented at: 2013 Gastrointestinal Cancers Symposium; January 24-26, 2013; San Francisco, CA. Abstract 309.
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