Advanced care planning and end of life care guidance and support

When a person is approaching end of life the focus of care may change and nutrition support will then centre on quality of life including comfort, symptom relief and enjoyment                    

The provision of food and drink should be enjoyable for the patient with a focus on comfort and palliation rather than aiming to achieve a prescribed daily nutritional intake.                    

Objective measures such as regular weights and food records will not impact on the level of care; therefore it should be considered to omit them.                     

Nutritional care should be individualised according to the patients’ disease and stage of their illness and can have physical, social, cultural and emotional aspects. We need to alleviate any pressure on the patient to maintain a normal diet. For some a nourishing diet may be suitable but for others a focus on increasing intake may add to their anxieties and stress.                     

• Provide reassurance to patients and family that the changes are often a natural response to the illness as the body starts to slow down
• Manage symptoms related to constipation, pain and depression.
  • Depression and constipation may manifest as disinterest in food or food refusal
  • Oral thrush, poor dentition, dry mouth and sore mouth may cause difficulty eating and lead to anorexia
• Consider the environment, the meal time experience, the social aspects, smells and the presentation of the food all can have an impact on appetite, intake and quality of life.
• Offer and encourage the individuals preferred food and drink; however please note that for some people with dementia preferences can change, and some people start to prefer food and drink that they previously disliked. Some people with dementia develop a preference for sweet foods so these may be more appetising than savoury foods.
• Encourage a little and often approach with food and drink. Many elderly people (with or without dementia) have small appetites, and nutritional needs are more likely to be met with six or so small meals / snacks rather than three bigger meals.
• Ensure appropriate food and drink is available throughout the day and night so that a person can be encouraged to eat and drink whenever he/she is most alert.
• If a person with dementia is frequently awake at night consider whether he/she is hungry.
• Encourage higher calorie foods and drinks. Avoiding high fat and high sugar foods at this stage is unlikely to be beneficial, these foods are often less palatable and may increase the risk of malnutrition.
• Consider food fortification (e.g. dried milk powder can be added to milk for cereal or drinks, custard, porridge, yogurt, milk puddings, cream soups, mashed potato etc.).
• People may ask for prescribed nutritional supplements however if a person is unlikely to consistently manage at least two bottles a day, then they are unlikely to derive any significant benefit from them. More importantly these do not contain anything which can’t be found in food, and most people prefer the flavour of ordinary food. Food means so much more to people than simply nutrition, and at the end of life enjoyment of even small amounts of food and fluid is more important than its nutritional content.

• Gentle massage, skin care, music and conversation
• Keep the person company - talk to them, read to them, watch films together, or simply sit and hold their hand
• Even when people cannot speak or smile, their need for companionship remains. The person may no longer recognise you, but may still draw comfort from your touch or the sound of your voice