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ach of us will at 1 time or another be confronted with the inevitable: death. Even under the best circumstances, the end stages of life can bring emotional pain, sadness, guilt, anxiety, denial, dilemmas, and unrealistic expectations for both the terminal patient and his or her survivors.
       Take for example Mr. W, a 75-year-old resident admitted to a long-term care facility with the diagnosis of end-stage prostate cancer with metastasis to the brain and liver. Mr. W is alert but weak, is aware of his poor prognosis, and has chosen palliative care. Most of his life, Mr. W followed a heart-healthy diet and avoided sweets and fried foods. Prior to being admitted to the facility, he sustained a 20-pound weight loss within a 4-week period. Currently, he has no appetite and complains of food having no flavor. Mr. W’s son expresses concern for his father’s weight loss and lack of appetite. However, he also questions why his father’s meal plan does not limit foods high in fat and sodium, since his father has a history of heart disease.
       In its position statement,¹ the American Dietetic Association (ADA) states that “the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet. The Association advocates the use of qualified dietetics professionals to assess and evaluate the need for medical nutrition therapy according to each person’s individual medical condition, needs, desires and rights.”
       The following paragraphs describe the ADA’s position on diet restriction for specific disease states.
       Cardiac disease. Available epidemiological evidence indicates that as age increases above 44 years, the importance of elevated serum-cholesterol levels as a risk factor for coronary heart disease decreases and virtually disappears after the age of 65. Therefore, the appropriateness of low-cholesterol diet prescriptions for older adults in long-term care facilities is questionable. While practitioners working with older adults should certainly be cognizant of cardiac problems, malnutrition is a more serious threat than elevated cholesterol to the majority of older adults.¹
       Hypertension. Low-sodium diets are often poorly tolerated in older adults and may lead to loss of appetite, hyponatremia, or confusion. A decrease in food intake in reaction to a low-sodium diet has the potential to worsen a person’s nutritional status and facilitate the onset of cardiac cachexia, respiratory infections, or pressure ulcers. Diets low in sodium may be perceived as bland and tasteless, diminishing the pleasurable experience of eating and promoting unnecessary weight loss. The possibility that the benefit of antihypertension treatment does not extend to individuals beyond a certain age threshold has been supported by several researchers.¹
       Diabetes. Experience has shown that older adults in long-term care eat better when they are given a less-restrictive diet of “regular” foods rather than an energy-controlled diet. The current ADA position statement says, “The imposition of dietary restrictions on elderly residents with diabetes in long-term health facilities is not warranted.” It is preferable to make medication changes rather than implement food restrictions in order to control the blood glucose. A key element in the use of regular menus in long-term care facilities is consistency in carbohydrate intake at meals and snacks.¹
       Renal disease. Older adults with renal failure in conjunction with other chronic medical conditions often have a high incidence of malnutrition. In long-term care, the resident with renal disease requires special consideration. It is well documented that up to 50% of hemodialysis (HD) clients are malnourished. Interventions to correct protein/calorie malnutrition and a poor appetite may include liberalization of the diet. However, laboratory values, food intake records, and weight loss or gain should be closely monitored.¹

The Case for Diet Liberalization

       The trend toward diet liberalization for all residents in long-term care facilities is increasing. The position paper of the ADA clearly supports careful evaluation on an individual basis for therapeutic diet restrictions. For all residents in long-term care facilities on therapeutic diet restrictions, the following questions should be explored: Is a restricted diet necessary? Does the diet offer health benefits to justify its use? Therapeutic diet restrictions often negatively impact the flavor and variety of the food, which lessens plate appeal.

Risk Versus Benefit

       So what is the best diet for Mr. W? Is a therapeutic diet restriction indicated or realistic at this time? In order to answer these questions, the dietetic professional needs to conduct a risk-versus-benefit analysis. At this point in Mr. W’s life, the risk of further weight loss is greater than the risk of worsening heart disease. Discontinuation of a heart-healthy (low-fat, low-salt) diet would then make sense. In fact, including high-fat and high-calorie foods in Mr. W’s meal plan would help to prevent further weight loss. After all, what good is a restrictive diet for a specific disease if the person is not going to live long enough to benefit from this preventative measure? Therefore, treatment of weight loss overrides the concern for an elevated serum cholesterol level or a history of hypertension.

What is Comfort or Palliative Care?

       The definition of comfort in the Merriam Webster’s Collegiate® Dictionary is “to soothe in time of grief or fear, a condition of ease or well-being, consolation or solace, one that brings ease or relief, capacity to give physical ease.” Palliative care is a comprehensive approach to treating serious illness that focuses on the physical, psychological, and existential needs of the patient. Its goal is to achieve the best quality of life available to the patient by relieving suffering, controlling pain and symptoms, and enabling the patient to achieve maximum functional capacity. Respect for the patient’s culture, beliefs, and values is an essential component. Palliative care is sometimes called “comfort care” or “hospice-type care.”²

Palliative Nutrition Care

       Palliative care and comfort measures in relation to diet mean developing meal plans that provide optimal quality of life. The goal of palliative nutritional care is to maximize intake without causing the resident any undue stress. A therapeutically restricted diet (ie, low-fat, low-salt, or low-sugar) is not generally as palatable or acceptable to the individual and can diminish an already fussy eater’s meal intake. Changes in taste or smell, bouts of diarrhea, constipation, nausea or vomiting, difficulty swallowing, and dry mouth contribute to a decrease in, or loss of, appetite. The dietetic professional’s goal should be to provide the resident with an ample variety of food offerings. What the resident likes is more important than what foods are “good” for him or her or are of “good” nutritive value. The quantity and type of food consumed is less of a concern than a pleasant and dignified dining experience.

Determining a Nutrition Plan of Care for the Palliative Resident

       The first step in determining a nutrition plan of care is to obtain the resident’s food preferences. If the resident is unable to communicate food preferences, family members or former caregivers should be contacted in an attempt to obtain this information. A good place to start is a list of the resident’s favorite foods, with relationship to food culture, ethnicity, religion, and/or personal meaning. The dietetic professional may then incorporate these favorite foods into the resident’s meal plan and offer suggestions for menu substitutions, nutrient-dense foods, and between-meal snacks and supplements. Consideration can also be given to altering the mealtime to times when the resident is free of pain and has the most energy. As the resident’s condition changes, the nutrition plan of care needs to be reevaluated and adjusted. A favorite food may become an aversion or foods once disliked may now be requested by the resident. Cold food is often better tolerated when a person is nauseated.
       The dietetic professional needs to educate the resident’s family and the healthcare team on the resident’s specific nutrition plan. By reinforcing the concept of comfort foods (eg, anything that appeals to the resident) and minimizing the necessity for therapeutic diet restrictions, the dietetic professional’s goal of improved intake at meals becomes easier.

Consistency Modified Diets

       The need for consistency modification should be assessed. The resident may have developed a chewing and/or swallowing problem that decreases food intake. In some cases, softer foods may be less tiring to consume. By simply providing a mechanically altered diet (ie, puree or mechanically softened diet) the resident will be able to markedly increase the quantity of food eaten.

Regulations and Policy Setting

       The enormity of healthcare regulation encumbers dietetic professionals’ confidence in involvement with decision making and with recommending care alternatives. Dietetic professionals must assist residents and the healthcare team members with both medical and quality-of-life needs. Input from the facility’s legal counsel and ethics committee should be utilized to develop end-of-life policies and procedures that address personal choices and appropriate palliative nutrition care. It is always best to set policy in advance of regulatory or legal issues.³ Furthermore, palliative intervention should be clearly described in the resident’s plan of care. Revising the plan of care to reflect changes in needs and choices of the resident in order to maintain the resident’s comfort and quality of life is essential.