DO WE HAVE TIME AND SPACE FOR DECISION-MAKING ON ENTERAL OR PARENTERAL NUTRITIONAL THERAPY (NPNT) IN PATIENTS UNDER PALLIATIVE CARE?
DOI:
https://doi.org/10.56238/arev8n5-035Keywords:
Palliative Care, Decision-Making, Nutrition Therapy, Clinical Nutrition, Clinical Practice GuidelineAbstract
Guidelines for nutritional care in palliative care (PC) emphasize that malnutrition is a common condition among patients receiving palliative care, compromising quality of life (QoL), intensifying adverse treatment effects, and increasing the risk of mortality. The objective was to identify criteria for prescribing enteral or parenteral nutritional therapy (EN or PN) in PC and to reflect on the decision-making (DM) process. International (ESPEN, 2021, 2024; INCA, 2015) and national (Brazilian Consensus on Oncological Nutrition, 2015; BRASPEN, 2019; and state protocols, 2025) guidelines were analyzed. The indication of EN or PN in PC remains controversial. Decision-making should take into account life expectancy (>3 months), inflammatory response, disease progression, symptoms, patient motivation, and the potential impact on QoL. Treatment may be beneficial for patients undergoing active therapy, with controlled inflammation and minimal weight loss. However, in the terminal phase, the focus should be on comfort, and EN or PN is not recommended, as it may increase suffering. Therefore, the indication must be individualized, based on the clinical condition and aligned with the expectations of the patient and their family.
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ARENDS, J. et al. Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines. ESMO Open, v. 6, n. 3, p. 100092, 2021. DOI: https://doi.org/10.1016/j.esmoop.2021.100092. Acesso em: 20 set. 2025. DOI: https://doi.org/10.1016/j.esmoop.2021.100092
ARNOLD, M. et al. Dysphagia in acute stroke: incidence, burden and impact on clinical outcome. PloS One, v. 11, n. 2, p. e0148424, 2016. DOI: https://doi.org/10.1371/journal.pone.0148424
ASSISTÊNCIA nutricional em cuidados paliativos adultos e idosos. Brasília: Secretaria de Estado de Saúde do Distrito Federal, 2025. Disponível em: https://acesse.one/NXf6k. Acesso em: 20 set. 2025.
BARROS, E. da S. et al. Validação do mnemônico NUTRIFICO. Revista Brasileira de Cancerologia, v. 70, n. 1, e-014415, 2024. DOI: https://doi.org/10.32635/2176-9745.RBC.2024v70n1.4415. Acesso em: 21 nov. 2025. DOI: https://doi.org/10.32635/2176-9745.RBC.2024v70n1.4415
BOZZETTI, F. Does nutrition for cancer patients feed the tumour? A clinical perspective. Critical Reviews in Oncology/Hematology, v. 153, p. 103061, 2020. DOI: https://doi.org/10.1016/j.critrevonc.2020.103061
BOZZETTI, F. et al. The prognosis of incurable cachectic cancer patients on home parenteral nutrition: a multicentre observational study. Annals of Oncology, v. 25, p. 487-493, 2014. DOI: https://doi.org/10.1093/annonc/mdt574. Acesso em: 21 out. 2025. DOI: https://doi.org/10.1093/annonc/mdt549
BOZZETTI, F. Is there a place for nutrition in palliative care? Supportive Care in Cancer, v. 28, p. 4069-4075, 2020. DOI: https://doi.org/10.1007/s00520-020-05505-x. DOI: https://doi.org/10.1007/s00520-020-05505-x
BRASIL. Ministério da Saúde. Política Nacional de Cuidados Paliativos. Brasília, 2015. Disponível em: https://bvsms.saude.gov.br/politica-nacional-de-cuidados-paliativos/. Acesso em: 20 set. 2025.
BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Instituto Nacional de Câncer. Consenso Nacional de Nutrição Oncológica. 2. ed. Rio de Janeiro: INCA, 2015. Disponível em: https://www.inca.gov.br/publicacoes/livros/consenso-nacional-de-nutricao-oncologica. Acesso em: 20 set. 2025.
BRASPEN – Sociedade Brasileira de Nutrição Parenteral e Enteral. Diretrizes BRASPEN para Terapia Nutricional em Cuidados Paliativos. 2023. Disponível em: https://www.braspen.org.br. Acesso em: 20 set. 2025.
CASTRO, M. G. et al. Diretriz BRASPEN de Terapia Nutricional no Paciente Grave. BRASPEN Journal, v. 38, n. 2, supl. 2, p. 2-46, 2023. Disponível em: https://www.braspen.org.br. DOI: https://doi.org/10.37111/braspenj.diretrizDOENTEGRAVE
COTOGNI, P. et al. Home parenteral nutrition versus artificial hydration in malnourished patients with cancer in palliative care: a prospective cohort survival study. BMJ Supportive & Palliative Care, 2020. DOI: https://doi.org/10.1136/bmjspcare-2019-001938.
COTOGNI, P. et al. Home parenteral nutrition versus artificial hydration in malnourished cancer patients in palliative care. BMJ Supportive & Palliative Care, v. 12, n. 1, p. 114-120, 2022. DOI: https://doi.org/10.1136/bmjspcare-2020-002731. DOI: https://doi.org/10.1136/bmjspcare-2020-002343
DISTRITO FEDERAL (Brasil). Secretaria de Estado de Saúde. Protocolo de Atenção à Saúde: Assistência Nutricional em Cuidados Paliativos Adultos e Idosos. Brasília: SES-DF, 2024. Disponível em: https://www.saude.df.gov.br.
ESPEN – European Society for Clinical Nutrition and Metabolism. ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition, v. 40, n. 5, 2021. DOI: https://doi.org/10.1016/j.clnu.2021.04.005. DOI: https://doi.org/10.1016/j.clnu.2021.04.005
FAVIERI, F. A. et al. The importance of nutrition in cancer care: a narrative review. Current Nutrition Reports, v. 13, p. 207-217, 2024. DOI: https://doi.org/10.1007/s13668-024-00491-2.
FEARON, K. et al. Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines. Annals of Oncology, v. 32, n. 12, p. 1475-1493, 2021.
FERRELL, B. R. et al. Integration of palliative care into standard oncology care. Journal of Clinical Oncology, v. 35, n. 1, p. 96-112, 2017. DOI: https://doi.org/10.1200/JCO.2016.70.1474. DOI: https://doi.org/10.1200/JCO.2016.70.1474
FERRELL, B. R. et al. Palliative Care for Patients with Cancer: ASCO Guideline Update. Journal of Clinical Oncology, v. 42, n. 6, p. 507-524, 2024. DOI: https://doi.org/10.1200/JCO.23.02432.
HEDBERG, A. M. et al. Parenteral nutrition in palliative cancer care: detrimental, futile, or beneficial? Current Oncology, v. 31, n. 5, p. 208, 2024. DOI: https://doi.org/10.3390/curroncol31050208. DOI: https://doi.org/10.3390/curroncol31050208
HORIE, L. M.; BARRÉRE, A. P. N.; CASTRO, M. G. et al. Diretriz BRASPEN de terapia nutricional no paciente com câncer. BRASPEN Journal, v. 34, supl. 1, p. 2-32, 2019. Disponível em: https://www.braspen.org.br.
HUI, D.; BRUERA, E. The last days of life: symptom burden and impact on nutrition and hydration in cancer patients. Current Opinion in Supportive and Palliative Care, v. 9, n. 4, p. 346-354, 2015. DOI: https://doi.org/10.1097/SPC.0000000000000171. DOI: https://doi.org/10.1097/SPC.0000000000000171
IAHPC – International Association for Hospice and Palliative Care. Definição de cuidados paliativos com base no consenso global. 2019. Disponível em: https://hospicecare.com/what-we-do/projects/global-palliative-care-definition/.
INSTITUTO NACIONAL DE CÂNCER JOSÉ ALENCAR GOMES DA SILVA. Consenso Nacional de Nutrição Oncológica. 2. ed. Rio de Janeiro: INCA, 2015. Disponível em: https://www.inca.gov.br.
JOLY, F. et al. Five-year survival and causes of death in patients on home parenteral nutrition for chronic and benign intestinal failure. Clinical Nutrition, v. 37, p. 1415-1422, 2018. DOI: https://doi.org/10.1016/j.clnu.2017.06.018. DOI: https://doi.org/10.1016/j.clnu.2017.06.016
MARTINO, R. et al. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke, v. 36, n. 12, p. 2756-2763, 2005. DOI: https://doi.org/10.1161/01.STR.0000190056.76543.eb
MAURIZ, P.; WIRTZBIKI, P. M.; CAMPOS, U. W. Protocolo de Cuidados Paliativos. Fortaleza: Instituto de Saúde e Gestão Hospitalar, 2014. Disponível em: https://isgh.org.br/intranet/images/Servicos/Protocolos/isgh_protoco_cuidado_paliativo.pdf.
MUSCARITOLI, M. et al. ESPEN practical guideline: Clinical Nutrition in Cancer. Clinical Nutrition, v. 40, p. 2898-2913, 2021. DOI: https://doi.org/10.1016/j.clnu.2021.03.005. DOI: https://doi.org/10.1016/j.clnu.2021.02.005
OMS – Organização Mundial da Saúde. Definição de Cuidados Paliativos. 2017. Disponível em: https://www.who.int/news-room/fact-sheets/detail/palliative-care.
PIRONI, L. et al. ESPEN guideline on home parenteral nutrition. Clinical Nutrition, v. 39, p. 1645-1666, 2020. DOI: https://doi.org/10.1016/j.clnu.2020.02.002. DOI: https://doi.org/10.1016/j.clnu.2020.03.005
SABATINO, A. et al. ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clinical Nutrition, v. 43, p. 2238-2254, 2024. DOI: https://doi.org/10.1016/j.clnu.2023.10.004. DOI: https://doi.org/10.1016/j.clnu.2024.08.002
SANDERS, J. J. et al. Palliative Care for Patients With Cancer: ASCO Guideline Update. Journal of Clinical Oncology, v. 42, n. 19, p. 2309-2327, 2024. DOI: https://doi.org/10.1200/JCO.24.00542. DOI: https://doi.org/10.1200/JCO.24.00542
THIBAULT, R. et al. ESPEN guideline on hospital nutrition. Clinical Nutrition, v. 40, p. 5684-5709, 2021. DOI: https://doi.org/10.1016/j.clnu.2021.09.001. DOI: https://doi.org/10.1016/j.clnu.2021.09.039
YANG, C.; WANG, X.; ZHANG, Y. Nutritional care for cancer patients: are we doing enough? Frontiers in Nutrition, v. 11, 2024. DOI: https://doi.org/10.3389/fnut.2024.1354016. DOI: https://doi.org/10.3389/fnut.2024.1361800
ZHANG, Y. et al. Nutrition in palliative care at the end of life: bibliometric and network analysis until 2024. Medicine, v. 104, n. 29, e40536, 2025. DOI: https://doi.org/10.1097/MD.0000000000040536. DOI: https://doi.org/10.1097/MD.0000000000043381
