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Artificial feeding & venting gastrostomy in palliative patients. Dr Nicholas Herodotou Macmillan Consultant Palliative Medicine L&D University Hospital, Luton/S. Beds Community, Keech Hospice. Topics . Case reports: Palliative Venting Gastrostomy (PVG) & Artificial Nutrition (AN)

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Artificial feeding & venting gastrostomy in palliative patients

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    1. Artificial feeding & venting gastrostomy in palliative patients Dr Nicholas Herodotou Macmillan Consultant Palliative Medicine L&D University Hospital, Luton/S. Beds Community, Keech Hospice

    2. Topics • Case reports: Palliative Venting Gastrostomy (PVG) & Artificial Nutrition (AN) • Ethics & Evidence • Development of a hospital pathway for AN & Venting PEG

    3. Artificial feeding in terminally ill cancer patients with bowel obstructionNicholas Herodotou. European Journal of Palliative Care, 2012; 19(5)

    4. Case 1 • 42 year female, married, 1 adult son • Peritoneal carcinomatosis Sept 2010 • Carboplatin 6 cycles (Ended Dec 2010) • Worsening disease Aug 2011 • 2nd course carboplatin (ended Jan 2012)

    5. Background • Two hospital admissions for vomiting & constipation during Aug-Dec 2011 • Admitted to Milton Keynes hospital March 2012 diagnosed small bowel obstruction • Persistent vomiting since Christmas 2011, not controlled by syringe driver • Previous admission to hospice • Not eaten-except for some milk

    6. PMH • Appendectomy 1996 • peritoneal adhesions 2000 • TAH, BSO for adhesions 2003

    7. Medication used in CSCI • Morphine 100mg • Haloperidol 3mg • Buscopan 100mg • Ondansetron SC PRN • Had used… • Maxalon • Cyclizine • Nozinan SC (made her drowsy)

    8. How I got involved? • Lecture to district nurses on venting PEG • District Nurse mentioned her patient • I agreed to review her via her GP • Admitted to L&D 29 March 2012

    9. Management • Didn’t appear to be in dying phase • Started dexamethasone IV 12mg & Losec • Switched morphine to Fentanyl 50mcg • Switched CSCI to: • Midazolam 5mg • Octreotide 600mcg • Nozinan 6.25mg

    10. Management • Enemas • IV fluids over weekend • Review after weekend; if still vomiting then Venting PEG and PEG feeding regime

    11. Reviewed after weekend • Ate for first time for weeks, but next day vomiting returned • Colicky pain, buscopan restarted • Looked more poorly • Not suitable for TPN feeding as prognosis less than 2 months • Agreed to Venting PEG & artificial feeding via PEG

    12. Surgeon vented patient on 3 April • Ate toast and oral food for first time! • Dietician advised trying high calorie drinks via PEG & clamping to allow absorption • Stopped octreotide, nozinan & steroids

    13. Outcome • Discharged home on 6 April • Kept on CSCI with midaz & buscopan • Added in voltarol via PEG for pain relief • Patient died at home peacefully 15 April, 12 days after procedure • GP & DN said family & patient felt it made a big difference to her quality of life

    14. Case 2 • 32 yr male Irish traveller, married, fifth baby due shortly • Admitted to the L&D with abdominal pain • Diagnosed advanced inoperable colon cancer, with small bowel obstruction • Profuse vomiting • IV fluids for days

    15. Prognosis about 2 months given • Some mobility & wanted to see baby born • Advise sought if AN appropriate • Patient agreed & IV feeding commenced • ?suitability for Home Parenteral Nutrition (HPN)

    16. Nutrition Team secured funding from PCT for home parenteral nutrition (HPN)-private service • Logistics of follow up as mobile caravan • Survived 4 months and saw his baby born

    17. What is a venting PEG?

    18. Venting PEG has a wider bore tube 18-25F (feeding is12F)

    19. Types of artificial feeding • Gastrostomy: PEG, RIG, SIG • Jenunostomy:PEJ, PEGJ, FNJ • Parenteral route : via Hickman or IV • Nasogastric tube (NGT)

    20. Routes for enteral feeding

    21. Ethics & Evidence • Autonomy • Beneficence • Non-maleficence • Justice

    22. Legal issues • Tony Bland case (1993 House of Lords ruling) • Mental Capacity Act 2005 • GMC guidance (End of Life Care & AN)

    23. Concerns around AN • Prolong suffering • Complications from procedure: Refeeding Syndrome • Delays preparing for death • When to stop feeding regime • Costly & labour intensive, especially HPN

    24. Evidence for artificial Nutrition (AN) in palliative patients • Medically assisted nutrition for palliative care in adult patients. Cochrane database of Systematic Reviews, 2008, Good P, Cavenagh J, Mather M, Ravenscroft P • No RCT or prospective controlled trials • Conclusion: “Insufficient good quality trials to recommend medically Assisted Nutrition (AN) in palliative care patients”

    25. Evidence for venting PEG1? • Retrospective study1 in 2002 looked at Palliative Venting Gastrostomy (PVG) over a seven-year period of 51 advanced cancer patients who had bowel involvement and symptoms of nausea and vomiting. • Of these patients, 41 (92%) had their symptoms relieved by PVG, and median survival after PVG insertion of all patients was 17 days 1Palliative venting gastrostomy in malignant intestinal obstruction. M A Brooksbank, P A Ashby; Palliative Medicine, 2002; 16: 520

    26. Hospital pathway for Venting PEG & Artificial nutrition in palliative (terminal) patients

    27. Why was it needed? • No guidance in place • Patients dying badly from uncontrolled vomiting • Terminal patients denied nutritional intervention

    28. How the pathways were developed? • Multi-professional team work • Persistence! • Mutual trust

    29. Home Parenteral Nutrition (HPN) pathway for terminally ill Patients with confirmed bowel obstruction Patient not eaten for >5 days, hunger symptoms, vomiting or dysphagia. No Prognosis 2-3 months? Yes Yes Has patient capacity to consent? Assessment by multi-professional teams involved to agree decision on HPN Address any symptoms-seek specialist advise if unsure. No Not suitable for HPN Yes If indicated Venting PEG prior to transfer to St Marks Refer to St Mark’s Hospital by consultant gastroenterologist. Discussion & document with patient/family on: goals, limitations, requirements, complications & stopping HPN. Consent form & patient leaflet Plan discharge & support by St Mark’s hospital/Macmillan service

    30. If prognosis <1 month • Can consider PEG feeding regime • Theory that some feed is still absorbed even in malignant bowel obstruction due to slow flow rate • Benefit?

    31. Pathway for Palliative venting gastrostomy (PVG) in terminally ill patients with confirmed irreversible bowel obstruction Uncontrolled vomiting due to confirmed bowel obstruction; patient has capacity to consent Under specialist advise, try & control the pain & vomiting symptoms with a Syringe Driver using various medications such as: morhpine, midazolam 5-10mg, Buscopan 60-120mg, Dexamethasone 12-16mg, cyclizine 150mg, nozinan 6.25-25mg, octreotide 300-1.2mg. (Minimum trial of 48 hrs) NO Are symptoms controlled? Yes Does 24 hour NGT trial 14F relieve symptoms? NO Remove NGT, sedate patient surgical/gastro/nutrition/palliative assessment for consideration of Venting PEG. Venting equipment for discharge & EOLC planning including info for community team Yes Pain review by Macmillan team pre/post PEG

    32. Summary • Consider venting Peg for uncontrolled vomiting 2nd to irreversible malignant bowel obstruction • Remember to consider artificial feeding if ethically appropriate: PEG or HPN • End of life does NOT mean End of Care!

    33. Finally, remember….

    34. The Art of medicine