To Feed or Not to Feed: Is That the Right Question?
Authors: Timothy Moynihan, Darlene G. Kelly, Michael J. Fisch
Journal: Journal of Clinical Oncology (2005)

Mr. Smith was a 54-year-old man with advanced non–small-cell lung cancer who had received two cycles of systemic chemotherapy for metastatic disease. He decided to not have any further chemotherapy. He had significant anorexia and cachexia, having lost 10 pounds in the last 2 months despite the use of megestrol acetate. He emphasized that he was neither hungry nor thirsty. At the clinic visit, it was evident that his family was quite distressed by his situation and had been strongly encouraging the patient to eat. They asked his oncologist about a feeding tube. The situation in the office was clearly an emotional one. Nutrition at the end of life is an issue that is fraught with multiple sources of confusion, contradiction, myth, and emotion. Anorexia and cachexia in the context of a terminal illness form a poorly understood syndrome mediated by multiple factors, including proinflammatory cytokines (such as tumor necrosis factor, interleukin-6, and interleukin-8), hormonal disturbances, muscle proteolysis, and lipid alterations. The net effect is the break of the linkage between the intake of nutrition, the laying down of new tissues, and the maintenance of a healthy state. Cancer anorexia and cachexia is a topic of interest to numerous investigators in basic and clinical science. Unfortunately, it is clear that artificial nutrition, defined here as administration of nutrition via tubes placed into the gut (enteral) or vein (parenteral), will not reverse this syndrome. In addition, the means by which artificial nutrition is administered may produce serious adverse effects. Nutrition issues in patients with advanced cancer are often addressed as a part of palliative care. Palliative care, as defined by WHO, is “the total active care of patients whose disease is not responsive to curative treatment.” This definition does not specifically include or exclude any type of therapy, such as artificial nutrition or hydration. Palliative care seeks to provide relief from symptoms caused by the terminal process and, in so doing, does not seek to hasten or postpone death. The essence of palliative care is to relieve suffering; it strives to minimize the adverse effects or complications of any medical procedures. One of the most important aspects of end-of-life palliative care is defining the patient’s goals and balancing these goals with the medical realities of the situation and the patient’s and family’s desires. Thus, it is essential for the physician to weigh the risks of any proposed treatment against the potential gain. Managing patients with severe cachexia in the setting of advanced cancer is often challenging because this syndrome unmasks or accentuates one or more challenging aspects of caring for patients toward the end of life (Table 1). From a legal perspective, most states consider artificial nutrition and hydration as no different from any other medical treatment, and, as such, these are generally regarded as extraordinary care. A patient’s cultural or religious beliefs may play a crucial role in the decision-making process because some faith systems place any extension of survival ahead of quality of life, where much of Western medicine now places the most emphasis. The physician must ensure that the patient and the family From the Mayo Clinic, Rochester, MN; and The University of Texas M.D. Anderson Cancer Center, Houston, TX.