Page 15 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

Nutrition:
Nutrition in the weeks and months prior to death is often challenging. The need for food and fluids
decreases as energy demands lessen with decreased activity. As body systems shut down, intake
decreases resulting in dehydration and altered metabolism. Protein‐calorie malnutrition and
dehydration impair skin turgor, leaving tissue susceptible to new breakdown or negatively impacting
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healing of existing wounds.

Normal healing requires adequate protein, fat, and carbohydrates, as well as vitamins and minerals.
Most diets are a combination of these elements so deficiencies of nutrients are uncommon. Loss of
protein and fluids from the wound, as well as the increased demands required to support the wound
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healing process, may increase patient nutrient needs. Oral nutrition is preferred. Suggest patients with
wounds choose foods high in protein, such as milk, eggs, cheese, tuna, fish, and meat. Beneficial snacks
include pudding, peanut butter and crackers, protein bars, and ice cream. The patient’s condition and
goals will ultimately determine his/her intake. For nutritionally compromised individuals, a plan of
nutritional support or supplementation may be implemented if consistent with the patient/family goals.
Before enteral or parental nutrition is used, a critical review of overall goals and wishes of the patient,
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family, and care team should be considered. Enteral tube feedings or parental nutrition should be
considered only if they are in line with the patient’s wishes and the treatment of protein‐calorie
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malnutrition will actually increase the possibility of healing. Support for the use of enteral nutrition to
prevent or heal pressure ulcers is conflicting. In some instances, the use of PEG tubes has actually been
shown to increase the risk of pressure ulcers, particularly in nursing home patients with advanced
dementia. Tube feeding necessitates the elevation of the head of the bed (HOB) increasing pressure,
shear and friction. Use of feeding tubes has not been found to improve survival or prevent aspiration
pneumonia. In addition to the lack of evidence in support for ulcer healing and prevention, patients
receiving tube feedings may also experience decreased human interaction as utilization of a PEG tube
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replaces the personal contact received when the patient is fed by another individual.

Food has strong emotional and symbolic implications encompassing nurturing, cultural and religious
traditions, and social values. Nutrition and hydration impact wound healing but cannot prevent an
individual with co‐morbid conditions from dying. Nutritional goals and interventions need to be
compatible with the patient’s condition and wishes. 10,11 Although some medications may stimulate
appetite, they may also hinder wound healing (corticosteroids, such as prednisone or dexamethasone)
or cause adverse effects for patients [e.g., DVT risk with megestrol (Megace®); sedation and xerostomia
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with mirtazapine (Remeron®)]. Therefore, non‐pharmacological approaches are recommended for the
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alert patient able to safely tolerate food and drink.
 Small, frequent meals of preferred food/drink
 Relax dietary restrictions (diabetic, sodium, etc) ordered to treat a specific condition
 Offer supplements to patients with protein, vitamin, or mineral deficiencies
 Keep water or other fluids within easy reach, encouraging small, frequent sips
 Offer easy to swallow comfort foods: gelatin, pudding, ice cream, popsicles, soup, etc. Consider
adding protein powder to foods, such as pudding, soups, or milkshakes, to increase protein
intake and thereby maximizing healing.

While the Agency for Healthcare Research and Quality (AHRQ) pressure ulcer prevention guideline
suggests that a serum albumin of less than 3.5 gm/dL predisposes a patient for increased risk of
pressure ulcers, one study reveals that current dietary protein intake is a more independent predictor
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than this lab value. Empirical evidence is lacking that the use of vitamin and mineral supplements, in the
absence of deficiency, prevents pressure ulcers. Avoid supplementing patients without protein, vitamin,
or mineral deficiencies. Over‐the‐counter vitamins and minerals are not regulated by the Food & Drug
Administration; subsequently, contents and price can vary. Vitamin C and zinc are often recommended
for patients with pressure ulcers. Vitamin C is needed for collagen formation and development of tensile
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