For some time I have been intrigued by patients who, thought to be dying, were put on the Liverpool Care Pathway (LCP) but instead of dying improved. Such cases of unexpected recovery, reported in the Daily Mail, were of patients on the LCP who had had their treatment, feeding and hydration withdrawn. In two recent articles, in Clinical Medicine and BMJ online, I argue that there is more to these stories than meets the eye. Looking back at similar hospital cases, I noted that these patients shared some characteristics in that they were often:
- vulnerable, due to their dependency, frailty, multiple co-morbidities and polypharmacy
- malnourished, although this wasn’t always obvious because nowadays people can be overweight/obese to begin with
- at risk of aspiration and put Nil By Mouth for a number of days
- given intravenous fluids (IV) for a number of days and became oedematous
- eventually given nasogastric tube feeding (NGTF) and
- a few days later found to have worsening chest function, presumed to be chest infection and general deterioration, which made them look as if they were dying
These elderly patients deteriorated after artificial feeding and/or IV fluids were introduced. When the feeding/ IV fluids were withdrawn as part of the LCP, their conditions improved. In one patient this happened twice and she even lived for a further 10 months.
For someone who is severely malnourished or has been on a prolonged fasting, the first few days of feeding are absolutely crucial. Too much food given too quickly can precipitate heart failure, due to the sodium and water retention and the lack of vitamins and electrolytes, which can also lead to a number of other deficiency syndromes. This is re-feeding syndrome (RFS) and can be fatal. As healthcare professionals, we rarely consider the possibility of RFS when our elderly patients deteriorate. Why? Because RFS presents a non-specific clinical picture, masked by co-morbid conditions. It usually manifests as general deterioration; patients become weaker and chesty. Professionals, believing their patients have developed chest infections, treat them with antibiotics but to no avail. These patients have cardiac failure and/or respiratory failure due to lack of potassium, phosphate, magnesium and B vitamins, all vital nutrients to deal with the sudden influx of carbohydrates.
RFS was first recognised when holocaust survivors and prisoners of war in Japan were freed. They were cachectic and when they were given food and sweets, many of them became unwell and some died.
I propose a step-by-step approach to feeding of malnourished frail elderly patients, as follows:
- correction of micronutrient deficiencies
- extremely cautious feeding, even perhaps more cautious than the current NICE guidelines
- restriction of fluids and sodium during the re-feeding period
- close monitoring, primarily clinical but also biochemical
- prompt action if an elderly patient who is on artificial feeding starts being unwell – think of reducing the feed and the amount of fluids.
The precise nutritional and fluid requirements of frail elderly medical patients unable to eat and drink adequately are, as yet, poorly understood. Even with present guidelines, caution with volume and content of artificial feeds and fluids is needed to avoid re-feeding syndrome and over-hydration.
To feed or not to feed? This is only half the question. Clinicians are advised to question not just whether, but also how little and how slowly to artificially feed and hydrate their elderly patient. That is the question.
- Tsiompanou E, Lucas C & Stroud M. Overfeeding and overhydration in elderly medical patients: lessons from the Liverpool Care Pathway. Clin Med 2013;13(3): 248–51 http://bit.ly/19QMwgx
- Tsiompanou E, Stroud M. Reply to “We need an alternative to the Liverpool Care Pathway for patients who might recover http://bit.ly/134SV6h