CASE 1

Frank had colon cancer and had started his third round of chemo. His nausea was fairly well controlled with antiemetics but his appetite was poor. His wife was concerned that he was not eating enough.  During his check-up with his med/onc, she said, “It doesn’t matter what I fix, he won’t eat.” Frank protested, “Nothing tastes good.”

I wanted to address the concerns of Frank’s wife while honoring his autonomy, but what was the best way to do that? It’s easy to jump right into problem solving, but before introducing any nutritional education I needed to understand her concern. It may seem obvious that she was worried that not eating meant he would not be able to tolerate his treatment. But concerns usually have many layers and “drilling down” (gently) revealed a lot.


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His wife prided herself on her cooking, telling me, “I’m a really good cook.”  Frank nodded in agreement. And there was more; she considered his cancer diagnosis as something they were fighting together. Her part was taking care of him by fixing the foods he liked. While she had little control over the rest of his treatment, preparing good and nutritious food was something she could be in charge of. His difficulty eating negated her contribution to his care. It was important to remind her of why cancer patients lose their appetite. Treatment itself can cause nausea, and nausea impacts our desire to eat. I asked her to remember the last time she had a stomach flu. What would her response have been if someone tried to coax her into eating?

DISCUSSION

When a patient like Frank has trouble eating, the stakes are ratcheted higher because his family equates his poor appetite to giving up. Nutritional education is one strategy, but first we must assess a patient like Frank’s current situation in order to tailor the content of our teaching. Lack of appetite is not unusual in cancer and normalizing this can reduce the stress associated with not eating.

An essential step is to rule out obstacles to poor appetite. Was he taking his antiemetics correctly? Often “as needed” nausea meds are interpreted by lay persons as “don’t take unless you are vomiting.” Poor appetite can be linked to low grade/ongoing nausea, what a patient may describe as queasiness or no interest in eating.  Frank said, “Nothing sounds good to eat.” Constipation may also contribute to nausea so assessment and education regarding a good bowel regimen is important.

Once an assessment is completed we can initiate an educational discussion such as:

Utilizing strategies for making eating more appealing Small frequent meals should be offered with a larger amount in the morning—this is different than our cultural tendency to have the larger meal in the evening.  Mornings are when the patient will better tolerate food.  Food should be served on a small plate since a large plate of food can be overwhelming to someone who already has a poor appetite. Even before they start to eat, seeing a large amount of food may be so daunting it negatively impacts the desire to eat. Have families be cautious about serving foods with a strong aroma or ones that create a strong aroma when being prepared, even if those are foods the patient has preferred in the past. Taste changes because of disease and/or chemo. Have the family keep a log of food intake and be certain the physician knows how much the patient is eating. Appetite stimulants may be useful.1

Create an environment conducive to eating  Think of how the ambience of a restaurant enhances our eating experience. Remind them of this. Can Frank’s wife create an atmosphere that encourages eating? Cheerleading as a strategy for promoting eating almost always back fires. “You can do it!” as a large plate is placed in front of him creates tension, which does not promote eating. Remember his body is saying no to food.

When a patient reaches end of life the loss of appetite is intrinsically linked to that phase of disease. Anorexia at this stage is linked to disease rather than treatment. It is natural not to want to eat at end of life. Studies show that people at EOL are not thirsty or hungry because the disease itself causes a lack of appetite. The patient dies from the disease not from withholding food. Families need to be reminded of this again and again since it goes against our natural inclinations. Encourage the family to continue to offer food. Treat eating like taking medicine, eat even if no appetite but never to the point of discomfort or emesis.2