TPN in hospice?

[Stcroix, ASN, PhD, RN]

This week I got a new patient, a very sick fellow. He is an alert and oriented walkie talky with serious problems.. He was just sent home from a cancer center where he got the news "we cant do anything more for you" He has been fighting bladder cancer for a year. He now has 2 nephrostomy tubes, an ileostomy,a peg tube for decompression because his bowels are completely blocked and he was vomiting. The decision was made to run TPN into a port. I have not been with hospice too long and was kind of surprised about the TPN. I guess I can understand because we do tube feeding often, but TPN seems kind of I dunno, heroic? Not making a judgement here, just surprised I guess. Daily visits to hang new bags, family wont participate. Doc says we will do it for as long as it works. Anyone have patients like this?

[TammyG]

I have had many TPN patients in hospice, but I am pretty sure that they all came in already receiving TPN. There are many reasons why TPN might make sense, even in the long term. For example, we had a man with short bowel syndrome from multiple surgeries and he had been on TPN for two years before entering hospice. I can't recall any patients starting TPN after being on hospice, however.

[Call me Al]

I have been in hospice for 5 yrs and have never had a pt on TPN.

[sammiesmom]

I did hospice for a short while and we have patients on tube feeding. The medical director frowns at this and something we always have to educate family. I think if it is getting paid for by insurance, keep it if it boosts the patient's morals and allows him to be more comfortable.

[4boysmama]

I have had several hospice pts on TPN. In the case of your patient, the TPN isn't going to measurably prolong his life, because the cancer and he obstuction will likely force his decline pretty rapidly.

[coffeetalker]

Been doing hospice for coming up on 9 yrs- in all that time one pt on TPN- and she was young with 2 small kids; seems like either the hospice MD or you should be asking 'what is the goal of the TPN'- ie- anniversary/ an event that your pt is waiting for or is this indefinitely.... also what about all those labs to determine the 'lytes in each bag? "As long as it works" could be a long time- I would talk to your clinical manager as this case would bug me.

[Jensmom7, BSN, RN]

Have never had a patient on TPN, but several were getting tube feeds.

Generally, I enlist the SW and Chaplain to help me with patient/family education.

We instruct that as people decline, their appetite also declines and they start eating and drinking less. We also point out that as the gut starts to shut down, continued feeds can be uncomfortable and result in symptoms such as pain and vomiting.

Instead of arbitrarily stopping all tube feeds, we have had pretty good success when we tell families that we can mimic that natural decline by gradually decreasing the amount of feed.

That has a twofold benefit. Families don't feel so much that their loved one is "starving to death" (even though we know they aren't), and it helps the families who really didn't want the tube to begin with but were pressured into it by doctors and/or that one forceful family member to feel less guilt over their decision.

Our Medical Director stresses in IDT meetings that tube feeds are definitely NOT part of a Hospice POC but will defer to our judgment when we have families who just aren't ready to stop them.

[Kitiger, RN]

I've known 2 cancer/hospice patients who received TPN. One was a patient (a doctor), and the other was a friend. Both did it to feel better, to have some energy, and to be able to do things. One died within a month, the other lasted a little longer. Both were able to be somewhat active almost up to the last.

TPN does have a place in hospice.

[Jack Hazz, BSN, RN]

I agree. Most of hospice patients with TPNs are already on it prior to being admitted. I recently had a patient on TPN and I was horrified as my last TPN experience was 2 years ago. Good thing she uses CADD pump which I am familiar with and it all came back to me and went like a breeze. We rarely have TPN patients but since I became the CM for that patient and the family told my supervisor how great I was with the TPN (LOL!!!), we got 2 more TPN patients after that and curiously, they all went to me...yeah, I was very surprised (with one eyebrow raised all the way to the ceiling)!

[nutella, MSN, RN]

I am not per se against TPN in hospice. But I think it has to clear what the expectations are and if it is of any benefit at that time.

Commonly those larger amount of iv lead to congestion and fluid overload at the end of life, which is a reason to be mindful of why, how, and when to use TPN. If TPN is the only thing that keeps you alive but everything else is falling apart, it will only prolonge suffering. Oftentimes it is better to have things develop "the natural" way. But, that requires to understand that dying is not optional....

[toomuchbaloney]

Interesting topic and good discussion, in my opinion.

I think that whether or not our patients are allowed TPN on their POC is largely dependent upon the philosophy of the medical director and the funding of the agency.