How Often Can We Justify Parenteral Nutrition in Terminally Ill Cancer Patients?

iting five months after his initial diagnosis. He had already undergone a gastrojejunostomy and had been assessed at the cancer clinic. No oncological options were felt to be beneficial. He reported increasing problems with oral intake over the previous month and was vomiting 8-10 times a day. On examination he was noted to be cachectic but was orientated and alert with a mini-mental state examination of 30/30 (10). A gastroscopy was performed which showed a 90% obstruction at the gastric outlet. It proved technically impossible to do a percutaneous gastrostomy during this procedure. No further surgery was deemed feasible. The patient was increasingly distressed by his inability to tolerate oral intake and by his fear that he would rapidly deteriorate from malnutrition. As a result, on Day 7 of admission PN was started. The nausea and vomiting settled, presumably due to pharmacological management and the absence of oral intake. As the patient had initially requested a home discharge, attempts were made to facilitate this. A problem arose when the program responsible for providing home PN felt that, given the patient's diagnosis, he would not benefit from PN. The patient became extremely upset and stated that he felt he was "falling through the cracks". He and his family lost their enthusiasm for a home discharge and requested to remain in hospital so that he could continue to receive PN. Thirteen days after PN was started, intravenous antibiotics were required for an infection related to the PN access site. PN continued for 29 days. During this time the patient continued to deteriorate steadily with increasing weakness, jaundice, and ascites. Physical symptoms such as pain and nausea were easily controlled with minimal medications. Despite the obvious progression of disease and increasing drowsiness, the patient continued to request that the PN be maintained. He was in an unresponsive condition for 48 hours before his family agreed to discontinue the PN. Death occurred two days later. ~ Many terminally ill cancer patients present with a combination of anorexia, cachexia, asthenia, and chronic nausea. This has been referred to as the cachexia/anorexia syndrome. The associated weight 'loss has been reported to occur in 80%-90% of patients (1). However, this prevalence varies depending on the type of primary tumor and the stage of the disease. Cachexia/anorexia is relatively uncommon in patients with breast adenocarcinoma while it is very common in lung and pancreatic adenocarcinomas (2). Unfortunately, the ideal clinical management of removing the underlying cause is not possible in the majority of patients with advanced malignant disease. Parenteral nutrition (PN) has been proposed as an approach to providing nutritional support to cancer patients and thus for improving clinical outcomes (3). .There are numerous reports in the literature discouraging the use of PN as an inappropriate treatment for advanced cancer patients, because of its high cost, potential complications, and the ethical considerations surrounding it (4-9).Nevertheless, very few of these reports state categorically that PN is never justified in this patient population. The questions that health care professionals working with advanced cancer patients have to consider are: