Feast or Famine?: Parenteral Nutrition at End of Life for Patients with Cancer

Abstract: Parenteral nutrition (PN) support for cancer patients is controversial. Professional guidelines, including the American Society of Clinical Oncology (ASCO) state clinicians “should not routinely offer enteral feeding or parenteral nutrition to manage cachexia” in patients with advanced cancer or at end of life (EOL). This panel will present multiple views on the utility of PN in cancer patients and review the current state of the science and real-world practice.

Our first presenter will question the utility of PN at the EOL, reviewing the complex metabolic and physiologic factors that distinguish cancer-related anorexia and cachexia from other malnutrition, the lack of evidence for improved survival or quality of life with PN, and potential risks and complications. They will review conflicts between patient autonomy and requests for non-beneficial treatment in the context of individual patient care and resource utilization.

Our second presenter will challenge ASCO guidelines using a pediatric framework. There are no studies on PN outcomes at EOL in children, and guidelines do not account for the physiological differences between patients or reasons for malnutrition. Nutrition is layered with cultural and personal meaning and necessitates a more nuanced approach. They will present an alternative perspective where PN is treated like other life sustaining therapies: with individualized assessment of physiological reasonability, risks and benefits, and patient/family goals and values.

Finally, we will open the discussion to participants and attempt, as a group, to reach consensus for a framework about the utilization of parenteral nutrition for cancer patients at end of life.

Keywords: Cancer, End of life, Artificial nutrition and hydration