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Doctor, Does This Mean I'm Going to Starve to Death?

From the Cancer Research United Kingdom Department of Medical Oncology and the Department of Palliative Medicine, Christie Hospital National Health Service Trust; Regional Department of Home Parential Nutritin, Hope Hospital, Salford; and the University of Manchester Department of Bioethics, Manchester, United Kingdom.

Address reprint requests to Gordon C. Jayson, FRCP, PhD, Cancer Research UK Department of Medical Oncology, Christie Hospital NHS Trust, Manchester, M20 4BX, United Kingdom; email: gordon.jayson{at}christie-tr.nwest.nhs.uk

Here's the Case

"Shirley" is a 60-year-old woman who presented with abdominal pain and distension 10 years ago. Following a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy she had been diagnosed with an International Federation of Gynecology and Obstetrics stage IC poorly differentiated endometrioid cancer of the ovary and had subsequently received six cycles of carboplatin, cyclophosphamide, doxorubicin, and ifosfamide. She was well until 3 years ago, when a computed tomography scan showed extensive disease in the omentum and pelvis. A laparotomy revealed inoperable intra-abdominal disease that was histologically consistent with recurrent ovarian cancer. She received six cycles of carboplatin and paclitaxel. A computed tomography scan confirmed a partial response, and Shirley remained well until 2 years ago. At that time, she developed abdominal distension, colic, and flatulence, due to progressive disease. She was treated with single agent carboplatin, but after two cycles, Shirley presented with the symptoms and signs of bowel obstruction. Surgical management was not an option, given the extent of the intra-abdominal disease. Nausea and abdominal discomfort were well controlled medically, and she reported a good quality of life, although she vomited after eating. Following a series of long discussions with Shirley, her relatives, nursing staff, and a number of physicians, a percutaneous venting jejunostomy was fashioned to permit her to eat and drink. This drained 2 L of fluid per day on average. At this point, Shirley and her medical team began to consider whether intravenous nutritional support should be initiated.

Ovarian cancer is a common malignancy in the Western world, causing approximately 15,000 deaths in the United States each year and 5,000 in the United Kingdom. Between 25% and 59% of these women die as a result of bowel obstruction associated with advanced malignancy [1]. Patients for whom surgical palliation is not possible have a median survival of approximately 2 months [2].

Many patients or families raise the possibility of using total parenteral nutrition (TPN) when a patient with advanced cancer is eating poorly and losing weight. Generally, in these situations, a clear, careful, discussion should take place to explain why TPN is only an option for rare selected cases, given that the vast majority of patients with advanced cancer die from the cancer process, not starvation. Loss of appetite, fatigue, and weight loss can, in fact, be part of the dying process. Randomized studies of nutritional support in patients with advanced cancer have failed to show any benefit in improving either survival or quality of life [3,4].

What about patients, like Shirley, who have a bowel obstruction as the cause of their inability to obtain adequate nutrition? Could this be a situation whereby TPN might improve survival and quality of life?

In addressing this question for an individual patient, it should first be noted that the symptoms of malignant bowel obstruction include nausea, vomiting, abdominal distension, and abdominal pain [5]. One guiding principle is that medical management to control these symptoms of bowel obstruction should be successful before considering TPN.

Next, it needs to be accepted that there are risks associated with the administration of TPN. TPN is an invasive procedure that requires close monitoring. Between 9% and 22% of patients with advanced disease who receive TPN are admitted to a hospital with complications of one sort or another [5,6]. Some form of central vascular access must be obtained, with the attendant risks of infection. These risks must be clearly explained to and understood by the patient before any decision is made regarding the use of TPN—particularly as thrombosis or sepsis secondary to central venous access may shorten an already reduced life expectancy.

So how should a physician respond when a woman with an inoperable malignant bowel obstruction asks, "Doctor, does this mean I'm going to starve to death?" In the absence of clear data from randomized trials, we recommend the following approach: first, consider the overall condition. The majority of patients will have rapidly progressive disease, dysfunction of other organ systems, and poor performance status, and will be too ill for consideration of TPN. In these cases, the doctor should answer, "No, you won't starve to death," noting that, in general, discussions about the appropriateness of parenteral feeding should avoid the "sloganism of starvation" [7].

However, in highly selected cases, such as Shirley's situation, in which she has relatively isolated bowel dysfunction, published data suggest that TPN can improve the clinical outcome for some patients with inoperable malignant bowel obstruction [8-10]. Some small studies suggest an improvement in median survival from the initiation of parenteral feeding between 53 and 89 days [8-10]. Survival for some patients, however, may be far in excess of what is expected based on the median.

The patient must understand that the TPN will not, as far as we know, make the tumor itself better. Both patients and care providers need to be trained and supported by a hospital and community team familiar with the use of parenteral nutrition. In addition, any discussion regarding the initiation of TPN might also cover how the decision would be made to stop it. This can be introduced using language such as, "There may come a time when supported nutrition is of no benefit to you and the burdens outweigh its previous value."

The use of TPN in patients with malignant bowel obstruction raises, for health professionals, the same ethical dilemmas as other interventions that are not curative and have risks of serious side effects and expense. The general consensus is that nutrition, and particularly nutrition given parenterally or via nasogastric or gastrostomy tubes, is for all intents and purposes a treatment like any other [11]. It should therefore be offered to patients if it is effective and if it compares well with other treatments with regard to efficiency.

The Medical Ethics Committee of the British Medical Association has stated that when there is a possibility that treatment will benefit the patient, the treatment should never be withheld simply because withholding it is considered easier than withdrawing it [12]. The process of informed consent to any treatment should include a discussion regarding when that treatment might be withdrawn. Such a discussion, in the context of TPN, may undoubtedly be stressful for doctor and patient, but that is not a sufficient reason not to offer TPN.

Back to the Case

Given that Shirley was clinically behaving as if she had a "short gut," for which TPN has a clear indication, that her disease course had appeared relatively indolent up until this time, and as she did not have any organ dysfunction other than her gastrointestinal tract, TPN was initiated.

This decision was made after a great deal of thought on the part of both Shirley and her health care team. In particular, Shirley appeared capable and willing to undergo the blood draws and general monitoring required for the administration and continuation of TPN.

Now, 16 months later, her TPN is managed by the nutritional unit at a local hospital. She attends the outpatient department regularly for her jejunostomy tube to be changed and her progress to be monitored. She is able to go out, and she leads an independent lifestyle, changing her TPN bags herself. She continues to eat small amounts for enjoyment. In total, she has clearly benefited from the decision to institute TPN.

Thus, Shirley appears to be one of the relatively rare patients with malignant bowel obstruction for whom TPN can provide a true benefit in terms of improving both her quantity and quality of life. Better prospective research is clearly needed concerning the indications for and/or utility of TPN in patients like Shirley, who have an untreatable malignant bowel obstruction. An improved understanding of who will benefit from TPN will allow for easier decision making and easier discussions in the future.

Authors' Note

After acceptance of this manuscript, Shirley died as a result of ovarian cancer 21 months after initiation of TPN, having been independent 20 of those months.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

NOTES

Work performed at Christie Hospital National Health Service Trust, Manchester, United Kingdom.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

REFERENCES

1. Jong P, Sturgeon J, Jamieson CG: Benefit of palliative surgery for bowel obstruction in advanced ovarian cancer. Can J Surg 38:454–457, 1995[Medline]

2. Redman CW, Shafi MI, Ambrose S, et al: Survival following intestinal obstruction in ovarian cancer. Eur J Surg Oncol 14:383–386, 1988[Medline]

3. American College of Physicians Position Paper: Parenteral nutrition in patients receiving cancer chemotherapy. Ann Int Med 110:734–736, 1989

4. Barber MD, Fearon KCH, Delmore G, et al: Should cancer patients with incurable disease receive parenteral or enteral nutritional support?. Eur J Cancer 34:279–285, 1998

5. Baines MJ: ABC of palliative care: Nausea, vomiting and intestinal obstruction. BMJ 315:1148–1150, 1997[Free Full Text]

6. Cozzaglio L, Balzola F, Cosentino F, et al: Outcome of cancer patients receiving parenteral nutrition. JPN J Parenter Enteral Nutr 21:339–342, 1997

7. Ahronheim JC, Gasner MR: The sloganism of starvation. Lancet 335:278–279, 1990[Medline]

8. August DA, Thorn D, Fisher RL, et al: Home parenteral nutrition for patients with inoperable malignant bowel obstruction. JPEN J Parenter Enteral Nutr 15:323–327, 1991[Abstract]

9. Abu-Rustum NR, Barakat RR, Venkatraman E, et al: Chemotherapy and total parenteral nutrition for advanced ovarian cancer with bowel obstruction. Gynecol Oncol 64:493–495, 1997[CrossRef][Medline]

10. King LA, Carson LF, Konstantinides N, et al: Outcome assessment of home parenteral nutrition in patients with gynecologic malignancies: What have we learned in a decade of experience?. Gynecol Oncol 51:377–382, 1993[CrossRef][Medline]

11. McCann RM, Hall WJ, Groth-Juncker A: Comfort care for terminally ill patients: The appropriate use of nutrition and hydration. JAMA 272:1263–1266, 1994[Abstract]

12. British Medical Association. Withholding and withdrawing life-prolonging treatment. London, United Kingdom, BMJ Books, 1999

Submitted February 11, 2003; accepted October 27, 2003.

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				G. D. Aletti, M. M. Gallenberg, W. A. Cliby, A. Jatoi, and L. C. Hartmann Current Management Strategies for Ovarian Cancer Mayo Clin. Proc., June 1, 2007; 82(6): 751 - 770. [Abstract] [Full Text] [PDF]

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