¿TENEMOS EL TIEMPO Y EL ESPACIO PARA LA TOMA DE DECISIONES (TDEC) EN LA TERAPIA NUTRICIONAL ENTERAL O PARENTERAL (ENT) EN PACIENTES DE CUIDADOS PALIATIVOS?
DOI:
https://doi.org/10.56238/arev8n5-035Palabras clave:
Cuidados Paliativos, Toma de Decisiones, Terapia Nutricional, Nutrición Clínica, Guía de Práctica ClínicaResumen
Las guías para la atención nutricional en cuidados paliativos (CP) destacan que la desnutrición es una condición frecuente entre los pacientes en cuidados paliativos, que compromete la calidad de vida (CV), potencia los efectos adversos del tratamiento y aumenta el riesgo de mortalidad. El objetivo fue identificar criterios para la prescripción de terapia nutricional enteral o parenteral (TNP) en CP y reflexionar sobre la toma de decisiones (TD). Este estudio analizó guías internacionales (ESPEN, 2021, 2024; INCA, 2015) y nacionales (Consenso Nacional sobre Nutrición Oncológica 2015, BRASPEN 2019 y protocolos estatales 2025). La indicación de TNP en CP es controvertida debido a la escasez de evidencia sobre los beneficios en la CV y el riesgo de prolongar el sufrimiento. La TD debe considerar la esperanza de vida (>3 meses), la respuesta inflamatoria, la progresión de la enfermedad, los síntomas, la motivación del paciente y el impacto en la CV. El tratamiento puede ser útil en pacientes sometidos a quimioterapia y/o radioterapia activa, con inflamación controlada y mínima pérdida de peso. Sin embargo, en la fase terminal, el objetivo es el confort, y la terapia nutricional no se recomienda, ya que puede aumentar el sufrimiento. Por lo tanto, la indicación debe individualizarse, basándose en el cuadro clínico y en función de las expectativas del paciente y su familia.
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Referencias
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
