Guidelines for a Palliative Approach in Residential Aged Care

The reasons for malnutrition in older persons are multi-faceted and can even be associated
with the process of ageing, which affects food intake and body weight and can be intensified
by illness or disease [176] (Level II). Depression and adverse medication side effects are the most
common treatable causes of malnutrition. [181] Given the prevalence of depression for residents
of RACFs and the high medication rates, these factors warrants specific attention [181] (Level
IV). Advanced dementia, apathy, fatigue, and late-life paranoia (e.g. where the resident believes
that he / she is being poisoned via food or fluid intake) are other potential factors involved in
poor nutritional and hydration status of older persons. [176] There are also specific issues relating
to eating, feeding and nutrition for those with particular diseases or diagnoses. For example,
Kumlien and Axelsson (2002) [182] (Level QE) reported that a quarter of stroke patients suffered
from dysphagia and 30% had poor food intake and poor appetite. Older persons who have had
a hip fracture tend to have a poor nutritional status, as do residents with COPD or Parkinson’s
Disease [183,184] (Level EO; Level III-3).
The traditional practice associated with a palliative approach is that when interest in food and
fluid becomes minimal the individual should not be forced to receive them. [185] Indeed, eating
and drinking may no longer be relevant to the resident who has already withdrawn and whose
attention is now more inward. [186] For example, a study of 32 individuals receiving a palliative
approach explored whether the provision of limited food and fluids (only in response to a
request from the individual) would have an adverse effect on quality of life [185] (Level IV). The
results indicated that 60% (n = 20) reported that they never experienced any hunger or thirst
and that most (n = 27) remained ‘comfortable’ requiring only sips of water.
The difficulties the aged care team experiences are often due to different views on basic human
rights and whether interventions to maintain hydration and nutrition are inappropriate
active medical interventions instead of a palliative approach [185] (Level IV). Family members
may request that everything possible be done for their relative, including treatments that are
considered by care providers as invasive or potentially burdensome, contributing to increased
suffering and discomfort for the resident. [185] The aged care team needs to be able to initiate
discussions with residents and their families about the pros and cons of artificial feeding and
hydration [187,188] (Level EO; Level EO). Additionally, the aged care team needs to be aware
that the family may require support when they are faced with making such decisions on their
relative’s behalf [185] (Level IV).
Adequate discussion with the resident and their family regarding nutritional and hydration
needs may help to alleviate the psychological and social distress often experienced. The aged
care team member assisting with feeding should be seated at eye-level with the resident and take
time to establish and maintain a relationship with the resident to create an atmosphere that is
conducive to relaxing the resident. This approach to feeding enhances the resident’s nutritional
intake and improves his / her social well-being [104] (Level III-1).
Nonetheless, many people who are dying often receive intravenous fluids when they are no
longer able to maintain a normal fluid balance. [189] The main reason for this appears to be
a belief that dehydration in a person close to death is distressing. However, professionals
providing a palliative approach generally consider that artificial nutrition and hydration may be
detrimental. [185,186,189,190]
88 Guidelines for a Palliative Approach in Residential Aged Care