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Bioethics Notebooks XXVii 2016/1st

95

Clinical Cases in Clinical Practice

Bioethics Notebooks XXVII 2016/1ª.

Copyright Bioethics Notebooks

CASE: ONCOLOGY PATIENT NUTRITION

CASE: NUTRITION IN ONCOLOGICAL PATIENT

TERESA GARCÍA GARCÍA

Morales Meseguer General University Hospital Hematology and Medical Oncology

Avda. Marqués de Los Vélez, s/n. 30008 Murcia

[email protected]

1. Description of the clinical case

A 45-year-old male patient diagnosed 1.5 years ago

with undifferentiated carcinoma of the rectum,

treated with chemotherapy, chemo-radiotherapy,

surgery with finding of peritoneal metastases with

incomplete resection, and two other lines of

chemotherapy, He has started intermittent parenteral

nutrition three months ago (hospital admission three

nights a week), with clinical improvement and some

weight gain.

She was admitted to the hospital for pain in the

flank and left lower limb, and the CT scan showed a

large abscess in the left psoas and multiple peritoneal

implants with small bowel loops dilated at multiple

points, indicating entrapment at various levels due to

peritoneal disease. On admission, radiological drainage

of the abscess was performed, an- tibiotic and

analgesic treatment was administered and total

parenteral nutrition was indicated, in addition to oral

feeding that was tolerated, which was scarce.

The evolution is torpid, with initial improvement

but with no final resolution of the abscess, and with

progressive establishment of complete intestinal

obstruction, causing continuous nausea and vomiting,

which are more bearable than those of the abscess.

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Bioethics Notebooks XXVii 2016/1st

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vomiting. Throughout the hospitalization, it becomes

increasingly evident that the patient will not leave

the hospital because of the impossibility of providing

the care he requires at home, and that life

expectancy is several weeks at best. He maintains a

completely normal level of consciousness, and a

progressively worse general condition, with

hypoproteinemia and generalized edema.

At one point in the course of the patient's

evolution, we considered the continuation of

parenteral nutrition, which provided a high volume of

fluid, worsening the edema. However, the patient is

conscious, pain-free, weak but with good symptom

control, and absolutely unwilling to talk about the

situation. After discussing the case among the

responsible physicians, and with certain doubts, the

conclusion is reached that paren- teral nutrition is

only prolonging the final process, and in agreement

with the family it is decided to suspend it, leaving a

small amount of glucose saline as a daily infusion. The

patient maintains the nasogastric tube and the

impossibility of enteral feeding. Almost a week went

by without improvement or worsening. At the

weekend, the doctor in charge of the patient, as the

outcome did not seem imminent, decided to resume

parenteral nutrition. That night, the patient suffered

acute pulmonary edema and died 24 hours later.

Bioethics Notebooks XXVii 2016/1st

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Clinical Cases in Clinical Practice

2. Ethical considerations

This is a patient diagnosed with an incurable

neoplastic disease, in an irreversible situation, with no

other possibility of specific treatment. Due to

complications of the disease that make enteral feeding

difficult, he has been dependent for months on

intravenous feeding three nights a week. He is

admitted for a complication that seems solvable, in a

situation that does not seem to be imminent death, so

the basic treatment of the complication is indicated,

and the minimum necessary support, which includes

parenteral nutrition in this patient. In other cases of

advanced incurable and irreversible disease with short

life expectancy, parenteral nutrition is considered a

disproportionate means (it requires a central

intravenous line, continuous admission, repeated

analyses to adjust glucose and electrolyte intake, the

risk of infection is high and so is the cost). But in this

particular patient, whose oral feeding is insufficient,

this type of nutrition has been considered justified for

several months.

During hospitalization, with progressive worsening

and decreasing life expectancy, as well as the onset of

adverse side effects due to the same nutrition, it

seemed justified to withdraw it, considering that this

withdrawal would not be the cause of death. However,

given the chronification of the situation, and without the

possibility of oral administration, we raised the ethical

problem of the patient actually dying due to lack of

nutrition, and -with doubts- we decided to reinstate it. On

the other hand, neither the patient nor the family have

expressed any opinion on this issue, nor have they

expressed any desire to shorten the process (which

would probably not change the ethical approach to the

case, but would at least allow us to take into account

the patient's wishes and values).

This results in water overload which, together with

extreme weakness and other circumstances, eventually

leads to lung flooding and death.

We believe that the decision was appropriate, both at

the time of withdrawal and at the time of reinstitution of

parenteral nutrition. Although in retrospect, had we

known that restarting parenteral nutrition would

precipitate the outcome, or that life expectancy was so

short, we would not have done so.