Guidelines for a Palliative Approach in Residential Aged Care

functional status and quality of life. They also stated that the challenges faced by medical
practitioners to fulfil individual needs and preferences, both organisational and practical,
were not considered by any of the studies. Therefore, the gathering of additional data was
recommended based upon large-scale multi-centre trials to clarify any perceived benefits from
protein and energy supplements on mortality rates.
Another systematic review examined the benefits of protein energy supplementation in adults
(predominantly aged 70+), which included studies of oral supplementation, modification of
food constituents to increase energy density, and studies of enteral feeding [197] (Level II). The
reviewers concluded that weight and nutritional indices of adults might be improved by routine
nutritional supplementation. However, no reduction in mortality was found for nutritional
supplementation. The reviewers also noted that there remain uncertainties as to whether
supplements routinely provided can improve outcomes, particularly over longer periods of time.
Neither of the systematic reviews considered a palliative approach as a variable, so the results
may not be transferable to the aged care population. Further research is required.
Individuals with advanced dementia who have difficulty eating or swallowing are often given
enteral feeding to prevent aspiration pneumonia, ulcers or malnutrition. [195] However, there is no
evidence that tube feeding makes a resident with advanced dementia more comfortable, provides
any benefit (including longer survival), or prevents aspiration pneumonia [195] (Level IV). Several
studies have found that tube feeding is a risk factor for pneumonia and morbidity [195] (Level IV).
Concern exists that enteral and parenteral nutrition therapies are too aggressive and, therefore, do
not fit within the philosophy of a palliative approach [185,187,190,198,199] (Level IV; Level EO; Level
QE; Level EO; Level EO).
Tube feeding
Continuing percutaneous endoscopic gastrostomy (PEG) feeding when death is imminent
may actually cause discomfort due to the body’s limited capacity to tolerate such intake at this
time [190,199] (Level QE; Level EO). If the resident has been receiving sustenance via a PEG tube
then reviewing the benefits of this treatment should be discussed with the resident’s doctor [190]
(Level QE).
In making an informed decision about tube feeding, the resident’s best interest and
preferences are the cornerstone. When residents cannot speak for themselves, it is best to
gather as much information as possible from those who have known them best such as family
members. This proxy approach to decision making does not ensure that the interests of the
vulnerable resident are guaranteed, but it does reduce the likelihood that the values of one
individual will dominate.
Often the dilemma that families face concerns regarding when to discontinue PEG feeds
once they have begun [187,199] (Level EO; Level EO). Having family members involved in the
decision making process to pre-empt such concerns of the family members by recording what
interventions they consider that the resident would prefer. Everyone involved in the decisionmaking
process needs to be aware that withholding or withdrawing treatments is legally and
ethically sound if the decision is to be based on fully informed consent. [185,188]
Guidelines for a Palliative Approach in Residential Aged Care 91