Hospice, TPN, Ovarian Cancer

Published

Tell me if this makes sense:

Pt diagnosed with stage 3 ovarian 4 years ago. Cancer has metastized to line the GI tract and causing ascites. Basically has a non functioning GI tract. Can't eat or really drink anything. If she does it absorption will be impaired to say the least. Dr says that if she can't absorb anything she may last a month, if she can tolerate some then it may be 3+ months. So basically she is going to starve or dehydrate. She requested TPN. Have any of you heard of TPN being used in a case like this? I was under the impression TPN was not done in a hospice or home care setting. Is it justified and could it help (theoretically)?

Up Vote Up Vote ×
Specializes in Hospice.

My hospice uses TPN occasionally. We have our own pharmacy and they are able to formulate it fairly cheaply. We use it in cases such as this, especially if the patient has a lot of anxiety over starving to death. It is important to do lots of education on symptoms of end of life and that eventually the tpn will do more harm than good. This is seen in fluid overload, nausea, pain, increasing dyspnea, etc. Hope that helps.

Up Vote Up Vote ×
Specializes in PICU, NICU, L&D, Public Health, Hospice.

I had a patient a few years back...young woman with children...similar circumstances. There came a point that SHE knew that her TPN was making her miserable and she was finally able to find peace in mer mortality.

I cried the day she asked me to turn if off...to DC the order. Not because I knew she would die without it...heck she was going to die with it...but because I understood what a huge step this was for her in the process. She was able to explain to her girls 10,8,, and 6 that she didn't stop because she didn't love them and wanted to go...but that she loved them very much but couldn't stay. The TPN gave her a bit of time...time to attend her youngest's kindergarten graduation. Time to make a video for her daughters. Time to let her husband know that she really loved him and was sorry to leave him alone.

TPN cost my hospice agency a bit, but her peace of mind was priceless...and my agency knows this.

Up Vote Up Vote ×
Specializes in Hospice, Pediatric, OB/GYN.

TNP is appropriate in the hospice and home setting. But always remember it's about quality of life. If the TPN will bring improved quality to her life to her, even for a short period of time, then it sounds like it's worth it to her.

When speaking with her about it I would explain that you will do a trial period of TPN, have a goal date to re-evaluate whether or not it is helping. I would also be very specific about the pros and CONS of TPN and review them when you start it.

Good luck.

Up Vote Up Vote ×
Tell me if this makes sense:

Pt diagnosed with stage 3 ovarian 4 years ago. Cancer has metastized to line the GI tract and causing ascites. Basically has a non functioning GI tract. Can't eat or really drink anything. If she does it absorption will be impaired to say the least. Dr says that if she can't absorb anything she may last a month, if she can tolerate some then it may be 3+ months. So basically she is going to starve or dehydrate. She requested TPN. Have any of you heard of TPN being used in a case like this? I was under the impression TPN was not done in a hospice or home care setting. Is it justified and could it help (theoretically)?

yes, it is occasionally used, and no, it does NOT help.

it only adds more distressing symptoms on top of the ascites.

i'm 99%+ confident, she will not tolerate it.

and chances are, she will have to pay out of pocket, since the tpn would be extending her life (r/t her primary dx).

but NO, she will not starve.

she is too sick to feel hungy, and pelvic tumors have a way of suppressing appetite. :-(

it's imperative she is kept well medicated.

education is key here, warning her of likely symptoms if she still opts for the tpn (fluid overload, n/v, dyspnea).

denial is a potent motivator to keep going, regardless of risk and sacrifice.

and it's heartbreaking to watch.

regardless of her decision, remain vigilant and supportive.

leslie

Up Vote Up Vote ×

She is hungry actually. Today she ate some chips and cheese and seemed to tolerate them pretty well. No n/v at all. She knows it not a permanent fix but thinks it may improve what time she has left if it will give her some energy. She says the main reason she even feels bad at this point is that she is so weak. The ascites haven't returned yet... its been a week. She is one of those patients that continues to amaze us. Always so upbeat and positive and she always seems to beat the odds. (Been given 3 months to live at least twice in the past 4 years).

Up Vote Up Vote ×
Specializes in Hospice, Pediatric, OB/GYN.

She shouldn't have to pay out of pocket since it is related to her diagnosis and would not really be considered aggressive tx, at least that's how my hospice would view it. I know all of them view aggressiveness a little different. But, ours would say you are treating a symptom rather than the disease and if it helps it would improve her quality of life for a brief period of time. I would have to do some research, but I don't know that TPN really would prolong life at this stage.

Up Vote Up Vote ×
Specializes in PICU, NICU, L&D, Public Health, Hospice.

I am in Michigan and not all hospices here would agree to pay for TPN. It is absolutely all about interpretation of the rules and values of the company as they relate to care of the patient.

Up Vote Up Vote ×
Specializes in ED, ICU, PACU.

You have to keep in mind that cancer cells require more nutrients than normal cells & when nutrition is supplied the cancer cells feed first. Less nutrition can amount to slower growth of the cancer cells, in some cases.

Cancer cells literally steal the food away from the body's normal cells.

Up Vote Up Vote ×
Specializes in PICU, NICU, L&D, Public Health, Hospice.
You have to keep in mind that cancer cells require more nutrients than normal cells & when nutrition is supplied the cancer cells feed first. Less nutrition can amount to slower growth of the cancer cells, in some cases.

Cancer cells literally steal the food away from the body's normal cells.

This is true, but some patients still desire this intervention for a variety of reasons.

Up Vote Up Vote ×
Specializes in ED, ICU, PACU.
This is true, but some patients still desire this intervention for a variety of reasons.

Agreed.

Just trying to show that patients should be given full information from a variety of perspectives so they can give informed consent to whatever they choose to do.

Up Vote Up Vote ×
Specializes in LTC, Psych, Hospice.
I had a patient a few years back...young woman with children...similar circumstances. There came a point that SHE knew that her TPN was making her miserable and she was finally able to find peace in mer mortality.

I cried the day she asked me to turn if off...to DC the order. Not because I knew she would die without it...heck she was going to die with it...but because I understood what a huge step this was for her in the process. She was able to explain to her girls 10,8,, and 6 that she didn't stop because she didn't love them and wanted to go...but that she loved them very much but couldn't stay. The TPN gave her a bit of time...time to attend her youngest's kindergarten graduation. Time to make a video for her daughters. Time to let her husband know that she really loved him and was sorry to leave him alone.

TPN cost my hospice agency a bit, but her peace of mind was priceless...and my agency knows this.

I had a similar pt a couple of years ago, young children and all. We did TPN for a couple of weeks until the pt and her mom realized it was really not doing her any good and making her more miserable. It brought tears to my eyes reading this and remembering Gloria.

Up Vote Up Vote ×
+ Join the Discussion