Monday 10th September 2012
Macmillan Dietitian George Anastopoulos discusses dietary options for people in palliative care with co-morbidities.
People in palliative care with co-morbidities often receive differing nutritional advice from healthcare professionals. This can be a challenging situation to be in, as well as confusing or upsetting for the patients.
One of the most common medical problems for people in palliative care is diabetes. In these situations, the goal shouldn’t be tight glycaemic control but symptom control instead. We don’t want to put further restrictions on an already undernourished person.
Advising on a low sugar diet for diabetes is a reasonable option when diabetes isn’t well-controlled, eg when the blood sugars are constantly in double figures despite oral hypoglycaemic agents and/or insulin treatment.
Diabetes can have serious complications, so it’s important to liaise with the diabetes team to find out how far the disease has progressed. As a rule of thumb, 10g of carbohydrate raises blood glucose by 2–3mmol. Therefore for an undernourished patient with blood sugars of less than 10mmol, it’s probably okay to have ‘that trifle’.
Remember, these patients are likely to manage small amounts anyway, so a small pot of a dessert containing 20g or even 30g of carbohydrate is fine.
If the blood sugars are consistently high, eg greater than 15mmol, then it may be wiser to suggest a low sugar alternative, with extra calories from fat and protein. In cases where appetite is very poor and the patient only expresses a desire for sweet foods, then nourishment should become a priority and preferred food choices may be offered, irrespective of the sugar content.
Sometimes blood glucose rises due to other, non-dietary reasons. Blood glucose monitoring may be required and/or a review of the patient’s diabetes medication may be needed. If the patient is on a nutritional supplement, a fibre alternative may need to be considered.
Hyperlipidaemia and cardiovascular disease
People with a history of these illnesses may have been following a healthy eating regimen for years and it can be challenging to tell them that this may no longer be appropriate. Likewise, for people who follow a low-fat diet due to history of high blood lipids, it’s a good idea to check the result of their latest blood tests.
If you’re unsure, liaise with their GP or the hospital doctor as appropriate. Quite often (especially when approaching the terminal phase) cholesterol lowering medication is withdrawn from patients’ prescriptions because the focus has shifted.
Check if the patient is still immunosuppressed and/or having further chemotherapy. If they are, then a modified diet, which is low in bacterial/fungal counts, can reduce the risk of infections.
Generally, the level of restriction recommended is dependent on the grade of neutropenia. If the patient is no longer immunosuppressed and/or having further chemotherapy, then all neutropenic diet restrictions can be lifted.
- Emphasis should be on quality of life, so eating for pleasure can become the main priority.
- Patients get information from many sources.
- Check what the patient has been told before and reassure them that previous advice was correct at the time.
- Check with the patient’s GP or care team about the likely prognosis and act accordingly, taking into account the patient’s wishes.
- Nutritional support can change with disease progression.
For more on this topic, see the new e-learning package on Learn Zone.
We have more information about eating well.
Email George Anastopoulos, Macmillan Oncology Dietitian at Queen Mary’s Hospital, Sidcup.