1
PALLIATIVE CARE
2
OBJECTIVES
Know and understand:
• The roles of palliative and hospice care in caring for
seriously ill older patients
• The quality indicators for palliative care
• Techniques for communicating effectively when delivering
serious news
• How to assess and manage pain at the end of life
• Best methods for managing non-pain symptoms at the
end of life
• The physician’s role in completing a death certificate
• How health professionals can experience burnout
3
TOPICS COVERED
• Facts About the Care of People with Serious Illness in
the United States
• Overall Care Near Death
• Ethnographic Data
• Palliative Care and Hospice
• Quality Indicators for Palliative Care
• Communication
• Palliation of Symptoms
• Death Certificate Completion
• Health Professional Burnout
• Choosing Wisely Recommendations
END-OF-LIFE DEMOGRAPHICS
IN THE UNITED STATES
4
• In the United States, the overwhelming majority of deaths
occur in older adults
• Seriously ill patients spend most of their final months at
home, but most deaths occur in the hospital or nursing home
• Location of death varies regionally:
 Portland: 35% in hospitals
 New York City: >80% in hospitals
•
The need for paid caregivers or institutionalization in the last
months of life is much higher among poor individuals and
women
•
Older adults with cognitive impairment and dementia are
more likely to spend their last days in a nursing home
QUALITY OF END OF LIFE
IN THE UNITED STATES
• Typical deaths are:
 Slow
 Associated with chronic disease in people with comorbidities
 Marked by  dependency and care needs
• Quality of life during the dying process is often poor
because of inadequate treatment of distress; fragmented
care; poor or absent communication among clinicians,
patients, and families; enormous strains on family
caregivers and support systems
• Difficult decisions about use of life-prolonging treatments
are commonly necessary
5
6
WHAT IS PALLIATIVE CARE?
• Interdisciplinary care that aims to relieve
suffering, improve quality of life, optimize
function, and assist with decision making for
patients with advanced illness and their
families
• It is offered simultaneously with all other
appropriate medical treatment
OVERALL CARE NEAR DEATH
(1 of 2)
• The Hospitalized Elderly Longitudinal Project (HELP) and the
Choices, Attitudes, and Strategies for Care of Advanced Dementia at
the End-of-Life (CASCADE) are two studies that examined the end
of life for older adults
 HELP characterized the last 6 months of life and dying in 1,266
adults ≥80 years old. Investigators showed that people tend to
overestimate their chances of survival near the end of life
 CASCADE described the course of 323 nursing-home residents
with advanced dementia. Patients with advanced dementia were
under-recognized to be at high risk of death and received
suboptimal palliative care.
• The results of both studies highlight the need for clinicians to talk
with patients early about their preferences and to provide better
symptom control and palliative measures at the end of life
7
OVERALL CARE NEAR DEATH
(2 of 2)
• It is challenging to provide excellent end-of-life care due to difficulty
in being able to accurately prognosticate, especially in patients with
chronic illness where exacerbations and remissions are common
and unpredictable
• Available Prognostic Tools
– The Palliative Performance Scale: Embraces self-care function,
as well as ratings of mobility, activity level, oral intake, and level
of consciousness, and can be used for people with multiple
comorbidities
– Eprognosis: An online site, it is a repository of validated geriatric
prognostic indices helpful in clinical practice
– “Hospice in a Minute” is a free application for smart phones that
includes a section on hospice eligibility criteria for several
diseases
8
9
ETHNOGRAPHIC DATA
• Studies show that a patient’s and family’s ethnic, cultural, and
religious heritage can influence their responses to serious
illness, desire for aggressive care, death, grief, and mourning
• It is important for clinicians to determine who should be
present for delivery of bad news or discussion of care goals
• Not all patients and families from a particular background will
respond and make choices in a similar manner. Assuming
patients and families will do so can lead to misunderstanding.
• One way to introduce the subject is to ask, “Is there anything
about your culture or your beliefs that would be helpful for me
to know as we plan together for the future?”
10
PALLIATIVE CARE AND HOSPICE
• Palliative care: Interprofessional care that aims to relieve
physical and emotional suffering, improve quality of life,
optimize function, and assist with decision making for patients
with advanced illness and their families. It is offered
simultaneously with all other disease-modifying medical
treatments, either by the primary medical team or in
conjunction with a palliative care consultant.
• Hospice: Specialized palliative care limited to patients who
meet two criteria: their life expectancy is <6 months if their
disease takes its natural course, and they (or their proxies)
have elected to focus on comfort measures and forgo curative
treatment
11
THE HOSPICE MEDICARE BENEFIT (1 of 2)
• For beneficiaries with an expected prognosis of 6 months or
less if the disease follows its usual course, certified by 2
licensed physicians. Patients may revoke their hospice
benefit at any time.
• Medicare guidelines require that the patient be recertified
hospice-eligible every few months. If the patient is no longer
judged to have a remaining life expectancy of <6 months,
then he or she must be discharged from hospice.
• As of 2011, CMS enacted a new regulation on hospices
requiring a “face-to-face” visit for all patients entering their
third certification period (at 6 months of hospice services)
and every 60-day certification period thereafter to reevaluate
the patient’s prognosis
12
THE HOSPICE MEDICARE BENEFIT (2 of 2)
• Patients agree to forego curative treatments* and agree
that the care plan for the terminal illness will be
managed by hospice
• Includes: Physician services, nursing care, medical
equipment and supplies, medications, short-term
inpatient care for symptom management and family
respite, PT or OT, bereavement services, home-health
aide services
* Some hospices have “open access” and allow certain treatment to
continue
QUALITY INDICATORS FOR
PALLIATIVE CARE
• National Consensus Guidelines for Palliative Care
consist of 8 domains (see next slide)
• Emphasize the need for collaboration across health care
settings and incorporate the growing evidence base in
palliative care
• Research demonstrates palliative care improves quality
of life for patients and their families
13
NATIONAL CONSENSUS GUIDELINES FOR
PALLIATIVE CARE
Domain
14
Guideline
Comments
1
Structure and Process
Describes the interprofessional team engagement with patients and
families, with emphasis on individual preferences
2
Physical Aspects
Describes the assessment and management of physical symptoms with
validated tools and a multidimensional approach to management
3
Psychological and
Psychiatric Aspects
Describes the collaborative assessment of psychological concerns and
psychiatric diagnoses to enhance care; outlines requirement for a
bereavement program for patients, families, and staff
4
Social Aspects
Identifies the essential elements of palliative care social assessment
and emphasizes identifying and supporting family strengths
5
Spiritual, Religious, and
Existential Aspects
Describes the assessment of these concerns through the disease
course and the importance of evaluation by the interprofessional team
6
Cultural Aspects
Defines cultural competence for the interprofessional team
7
Care of the Patient at the
End of Life
Describes communication and documentation of signs and symptoms of
the dying process with the family
8
Ethical and Legal
Aspects
Describes advance care planning, ethics of palliative care, and legal
issues
STEPS IN COMMUNICATING
SERIOUS NEWS
A systematic approach to delivering serious news can
foster collaboration among the patient, the family, and the
clinician and enhance the patient’s and family’s ability to
plan for the future, set realistic goals, and support one
another emotionally
• Prepare for the meeting
• Establish the patient’s understanding
• Determine how much the patient wants to know
• Tell the patient
• Respond to feelings and emotions
• Organize a plan and follow-up visit
15
PREPARING TO
DELIVER SERIOUS NEWS
• Plan what will be discussed
• Ensure that all medical facts and confirmations
are available
• Choose an appropriate, comfortable setting
• Deliver the news in person, privately
• Allow time for discussion
• Minimize interruptions
16
ESTABLISH THE PATIENT’S
UNDERSTANDING
Ask questions such as:
• “What do you understand about your illness?”
• “When you first had symptom X, what did you
think it might be?”
• “What have other doctors told you about your
condition or procedures that you have had?”
• “What are you hoping for or worried about?”
17
DETERMINE HOW MUCH THE PATIENT
WANTS TO KNOW (1 of 2)
Important to:
• Discuss the patient’s preferences and goals of
care to help guide treatment recommendations
• Understand what is important to the patient
• Determine if and how they want information
give to them
• Determine how they want to participate in the
decision making about their care
18
DETERMINE HOW MUCH THE PATIENT
WANTS TO KNOW (2 of 2)
• Patients with serious illness and their families
also may have different communication needs
from each other, and it is important to determine
this early
• Asking, “Are you the type of person who is
comforted by details and test data?” or “Would it
be helpful to discuss prognosis now?” both
allows the patient to remain in control as well as
determines the amount of information to which
they are exposed
19
20
TELLING THE PATIENT
• Deliver information in a sensitive, straightforward manner
• Avoid technical language or euphemisms
• Check for understanding
• Phrasing the includes a warning helps prepare patients
for bad news.
 “The report is back, and it is not as we had hoped.”
• Based on these discussions, clinicians may offer to
make a recommendation for care that is seen as
consistent with the goals and values a patient has
expressed
21
RESPOND TO FEELINGS AND EMOTIONS
• Patients often report not hearing anything more after
receiving notice of a life-threatening condition
• Responding to emotions demonstrates empathy and
may help patients to process them which may help them
assimilate information about their prognosis or treatment
options by making them feel understood
• One approach to responding to emotions is, first, to
recognize that the patient has had an emotional
response; next, to name the emotion; and finally to
explicitly respond to the patient in a way that
acknowledges the emotion. The recognition can be
verbal or nonverbal.
22
PLAN AND FOLLOW UP
• Organize a plan and follow-up




•
Address patient’s concerns in an immediate plan
Set an appointment for a follow-up visit
Discuss additional tests, referrals, sources of support
Provide information on how you can be reached with
additional questions
After patients’ preferences for end-of-life care are elicited
(perhaps through surrogates), they must be faithfully
communicated. Often, these preferences are
documented in advance directives or written orders
about cardiopulmonary resuscitation
23
ADVANCED DIRECTIVES
• Studies show that these documents and orders are often
ineffective in determining end-of-life treatment
• Physician Orders for Life Sustaining Treatment
(POLST)* : Constitute medical orders reflecting
preferences for cardiopulmonary resuscitation, medical
interventions, antibiotics, and artificial hydration and
transfer across care settings
• Research on the POLST program has shown a
decreased rate of unwanted hospitalization and better
documentation of preferences
* The forms may go by slightly different names, depending on the jurisdiction.
PALLIATIVE-FOCUSED SYMPTOM
ASSESSMENT
• Determine the patients goals of care
• Assess the patient’s functional status
• Assess the patient’s physical ability to tolerate different
treatment modalities and routes of medication
administration
• Determine the patient’s overall prognosis
Merge these data with the patient and family goals, values,
and cultural norms through a process of shared decision
making to develop a person-centered care plan
24
25
EFFECTIVE PAIN MANAGEMENT
• Know the types of pain
• Assess the patient’s level of pain
• Minimize pain with nonpharmacologic
techniques
• Add pharmacologic analgesia when needed
• Anticipate and manage the side effects of
opioids
26
PALLIATION OF NON-PAIN SYMPTOMS
• Constipation
• Delirium
• Nausea and vomiting
• Dyspnea
• Diarrhea
• Cough
• GI obstruction
• Loud respiration
• Anorexia and cachexia
• Depression
27
CONSTIPATION
• Common for terminally ill patients
• Caused by opioids, immobility, poor fluid intake
•
Treatment:
 Prophylactic laxatives: stool softener & bowel stimulant (docusate
sodium & senna or bisacodyl)
 If ineffective, add osmotic laxative (sorbitol, lactulose, polyethylene
glycol)
 If no bowel movement in 4 days, consider enema
 If impaction occurs: disimpact manually or with enemas before
starting laxative therapy
 If none of the above treatment strategies work and the constipation
is related to opioid use, consider methylnaltrexone bromide or
lubiprostone, both contraindicated with bowel obstruction
28
NAUSEA AND VOMITING
• Key facts
 Occur in 40% to 70% of patients with advanced
cancer
 May be caused by disease or its treatment
• Keys to successful management involves:
• Identifying the likely cause of the nausea
• Selecting a medication that works on the cause
• Giving around-the-clock medication if the nausea is
constant
• Evidence has shown that using topical lorazepam,
diphenhydramine, and haloperidol gel (aka “ABH” is not
effective and should not be used to treat nausea)
29
DIARRHEA
• Affects 7%‒10% of patients with cancer being admitted to
hospice
• Defined as the passage of more than three unformed bowel
movements within a 24-hour period
• Consider fecal impaction presenting as watery diarrhea in
immobile older patients on opioids
• Review medications for excessive laxative therapy
• Radiotherapy of the abdomen and pelvis can cause diarrhea
and responds to cholestyramine (off label)
• Diarrhea caused by fat malabsorption responds to pancreatic
enzymes such as pancreatin
30
GASTROINTESTINAL OBSTRUCTION
• Causes: Direct intraluminal obstruction by tumor,
malignant infiltration of the bowel wall, external
compression of the bowel wall, dysmotility, fecal
impaction, adverse effects of radiation treatment,
volvulus, and adhesions from previous surgeries
• Up to 50% of patients with ovarian and GI cancers have
malignant bowel obstruction
• Patients diagnosed with malignant bowel obstruction
have a median survival of 3 months
• High symptom burden with hypersalivation, nausea,
vomiting, colicky abdominal pain, anorexia, and weight
loss
GASTROINTESTINAL OBSTRUCTION
TREATMENT
• Evaluation and management depends on functional
status, goals of care, expected survival
• Treatment options:
 Surgical: Limited evidence for benefits in terms of quality of life
at the end of life
 Endoscopic techniques: Stents, best used for single point of
obstruction
 Medical management: Mainstay of treatment (combination
therapy with opioids, antispasmodics medications, antiemetics,
antisecretory agents, and corticosteroids)
 Nasogastric tubes: Temporary measure, used when patient
admitted with bowel obstruction awaiting further treatment
decisions
31
32
ANOREXIA AND CACHEXIA (1 of 2)
• Loss of appetite is almost universal among terminally
ill patients
• Anorexia in actively dying patients who do not wish to
eat should not be treated
• Symptoms of dry mouth should be treated
• Appetite stimulants (eg, megastrol acetate and
corticosteroids (used off label)) may benefit patients in
early stages but do not prolong survival or improve
function or treatment tolerance of cancer therapies,
and are associated with adverse events
33
ANOREXIA AND CACHEXIA (2 of 2)
• Encourage patients to eat whatever is most appealing,
without dietary restrictions
• In patients with advanced dementia, offer oral-assisted
feeding
• Provide patient and family education regarding the
normalcy of anorexia as a part of the end-of-life and
dying process
• Enteral feeding is not recommended at the end of life
as it does not improve quality of life or survival and is
associated with increased frequency of aspiration and
other complications
34
DELIRIUM (1 of 2)
• Common and distressing for both terminally ill patients
and their families
• Identify potentially reversible causes (infection,
impaction, uncontrolled pain, urinary retention,
medications, dehydration, and hypoxia)
• Use low doses of nonsedating antipsychotic
• Actively dying, nonambulatory patients may benefit from
sedating antipsychotic
• Avoid benzodiazepines
35
DELIRIUM (2 of 2)
Treatment Options:
• Nonpharmacologic approaches: minimizing noise, using
an orientation board, mounting a visible clock in the
room, using simple communication and minimizing
disruptions
• Pharmacologic approaches: Medications are indicated
either to ensure the patient’s safety or if the delirium is
causing distress
 Use low doses of nonsedating antipsychotic medications
 Actively dying, nonambulatory patients may benefit from sedating
antipsychotic medications
 Avoid benzodiazepines due to their association with paradoxical
agitation and worsening of delirium in older adults
36
DYSPNEA (1 of 2)
• Assessment
 Patient self-report is the only reliable measure
 Respiratory rates, pulmonary congestion, and lab
tests often do not correlate
 Goal of treatment is the subjective improvement of
breathlessness, rather than lowering the respiratory
rate to normal
 Often patients will report improvement in
breathlessness yet still breathe rapidly
37
DYSPNEA (2 of 2)
• Management
 Treat underlying cause, but do not delay symptom
management
 Opioids are the most effective treatment agent. Act
by decreasing the perception of dyspnea and do not
affect respiratory drive. Both oral and parenteral
formulations are effective
 Use O2 if saturation < 90% but use cautiously with
patients who retain CO2
 Cool air across the face by fan or an open window to
stimulate 5th cranial (trigeminal) nerve & reduce
dyspnea
 Benzodiazepines control anxiety but not dyspnea
38
COUGH
• Causes
 Production of excess fluids
 Inhalation of foreign material
 Stimulation of irritant receptors in the airway
• Management
 Treat underlying cause
 Add opioids if underlying disease not resolvable
• Dextromethorphan: few sedative effects
• Codeine, hydrocodone elixirs
• Methadone syrup for longer duration of action
 Nebulized anesthetic for irritated pharynx of local infection or
malignancy
39
LOUD RESPIRATION
• The inability to clear secretions from the oropharynx, resulting in
loud or “rattling” respirations at the end of life
• Caused by secretions oscillating up and down during inspiration and
expiration
• Treatment:
 Family education prior to its occurrence
 Anticholinergics to reduce secretions
Hyoscine (scopolamine patch) used off label, may be
sedating
Hyoscyamine
Glycopyrrolate
Atropine eye drops (off label)
 Careful monitoring is necessary when using anticholinergic
drugs as they can contribute to dry mouth, constipation,
delirium, and mucous plugging,
40
DEPRESSION (1 of 2)
• Under-recognized and undertreated in the terminally ill
• Diminishes quality of life, amplify pain and other
symptoms, and impair a patient’s ability to deal with the
emotions involved in saying goodbye
• Major risk factor for suicide and for requests to clinicians
to hasten death
• Vegetative symptoms (insomnia, anorexia, weight
change) may not be reliable because of underlying illness
41
DEPRESSION (2 of 2)
• Be alert for mood change, loss of interest, suicidal
ideation
• Treat aggressively: Antidepressants, psychiatric
consultation, cognitive-behavioral therapy are appropriate
• Consider ECT for those who are severely depressed and
when a rapid response is needed
• Involvement of clergy or pastoral care may be helpful to
help patients and families to work toward closure and
resolution
42
DEATH CERTIFICATE COMPLETION
• Death certificates are needed for personal, legal, and
public health purposes
• Accurate documentation of the cause of death and
communication with the family may help family members
with closure and peace of mind
• Physicians are responsible for completing the medical
portion of the death certificate, the “Cause of Death”
section and usually the pronouncement of death
 Cause of Death Section has 2 parts: 1) Immediate cause of
death and 2) Other conditions that contributed to the death
43
COMPLETING A DEATH CERTIFICATE
Points to Remember:
• Do not delay completion of the certificate. The burial or
disposition of the remains cannot proceed until a correctly
completed death certificate is accepted by the state.
• Print clearly or type using black ink.
• Do not use abbreviations.
• Spell out the month.
• Use a 24-hour clock.
• Complete all items, do not leave blanks. If necessary, use
“unknown.”
• Do not complete the medical information if another available
physician has more knowledge of the circumstances.
• Do not alter the document or erase any part of it.
44
HEALTH PROFESSIONAL BURNOUT
• Health care providers caring for patients and families at
the end of life are exposed to distressing emotional
situations and suffering this may lead to burnout
• Symptoms of burnout include irritability, insomnia,
forgetfulness, resentment, mental and physical fatigue,
social withdrawal, increased alcohol use, apathy, and/or
chronic sadness
• Burnout at work has both personal and professional
consequences. It is important for providers to be aware
of and address their responses to emotional situations to
prevent burnout.
45
CHOOSING WISELY
• Do not use topical lorazepam, diphenhydramine, or
haloperidol gel for nausea.
• Don’t recommend percutaneous feeding tubes in
patients with advanced dementia; instead offer oral
assisted feeding.
• Avoid using prescription appetite stimulants or highcalorie supplements for treatment of anorexia or
cachexia in older adults; instead, optimize social
supports, provide feeding assistance and clarify
patient goals and expectations.
46
SUMMARY (1 of 2)
• Palliative care aims to relieve suffering, improve quality
of life, optimize function, and assist with decision making
for patients with advanced illness and their families
• Palliative care is offered simultaneously with all other
appropriate medical treatment
• Communicating serious news requires preparation,
sensitivity to patient’s and family’s understanding and
emotional needs, and an organized plan and follow-up
• Pain should be assessed in all patients, and adequate
treatment may combine drugs with nonpharmacologic
interventions
47
SUMMARY (2 of 2)
• Clinicians should watch for and treat other symptoms at the
end of life: constipation, nausea & vomiting, diarrhea,
gastrointestinal obstruction, anorexia & cachexia, delirium,
dyspnea, cough, loud respirations, and depression
• It is a physician’s responsibility to properly complete a
patient’s death certificate
• Health professional burnout can occur in providers who are
not cognizant of their emotional responses to caring for
patients and families at the end of life
• It is important for health care providers to be aware of the
symptoms of burnout and seek appropriate help through
self-care or professional counseling
48
CASE 1 (1 of 4)
• A 75-year-old woman comes to the emergency department because
of new severe lower back pain.
 She reports no falls or trauma.
 She has had no new weakness or bowel or bladder
incontinence.
• History: CAD, diabetes mellitus, metastatic breast cancer
 The breast cancer was treated with chemotherapy and radiation
6 years ago.
 Three months ago she had right shoulder pain, and a scapular
metastatic lesion was diagnosed.
• Radiography of the lumbar sacral spine demonstrates metastatic
disease involving L1–L4 vertebrae, with severe pathologic
compression of L3.
49
CASE 1 (2 of 4)
• The patient is admitted for pain control.
The pain is controlled at rest with around-the-clock morphine.
The pain is aggravated by movement.
Because of its severity, she is unable to walk, spends all of her
time in bed, and is dependent in all ADLs except feeding.
• The patient acknowledges that her cancer is incurable and states that
she does not want further hospitalizations or interventions.
• The medical team recommends hospice.
The patient’s husband asks for information on hospice services.
50
CASE 1 (3 of 4)
Which one of the following is covered under the Medicare
hospice benefit?
A. Room and board in a long-term care facility
B. Nursing care in a postacute facility
C. Hospital bed and bedside commode for home
D. Private-duty caregiver at home
E. Medication for diabetes mellitus and coronary artery
disease
51
CASE 1 (4 of 4)
Which one of the following is covered under the Medicare
hospice benefit?
A. Room and board in a long-term care facility
B. Nursing care in a postacute facility
C. Hospital bed and bedside commode for home
D. Private-duty caregiver at home
E. Medication for diabetes mellitus and coronary artery
disease
52
CASE 2 (1 of 3)
• An 88-year-old woman is admitted to the hospital because she has
worsening abdominal pain.
• History: osteoarthritis, hypertension, hypothyroidism, metastatic
pancreatic cancer
• Pain management
 At home, she was taking oxycodone 5 mg every 6 hours, with
little pain relief.
 Because of pain and fatigue, she has spent most of the last
month in bed.
 In the hospital, the pain was controlled with IV hydromorphone,
with subsequent transition to long-acting oxycodone 20 mg
twice daily and short-acting oxycodone for breakthrough pain.
• Before discharge, the medical team meets with the patient and her
family. The patient’s husband asks the team to address her
prognosis.
53
CASE 2 (2 of 3)
Which one of the following is most predictive of a poor
prognosis?
A. Advanced age
B. Uncontrolled pain
C. Low performance status
D. Multiple comorbidities
E. Opioid dependence
54
CASE 2 (3 of 3)
Which one of the following is most predictive of a poor
prognosis?
A. Advanced age
B. Uncontrolled pain
C. Low performance status
D. Multiple comorbidities
E. Opioid dependence
55
CASE 3 (1 of 3)
• An 84-year-old man is admitted to the hospital for pain control
related to a pathologic pelvic fracture after a fall at home.
• History: Alzheimer disease, metastatic prostate cancer
• Hospital course
 Oxycodone is started, 5 mg every 6 hours around the clock, and
his symptoms improve.
 On hospital day 2, there is swelling in his left lower extremity.
 Ultrasonography reveals acute deep-vein thrombosis, and
anticoagulation therapy is started.
 Over the next few days, his oral intake decreases, and he
requires IV hydration.
• A bedside meeting is held with the patient’s wife, who has durable
power of attorney.
 She says that his appetite at home has been poor and that he
has lost 6.8 kg (15 lb) in the last 3 months.
 She asks what can be done to prevent further weight loss.
56
CASE 3 (2 of 3)
Which one of the following is the most appropriate
recommendation for this patient?
A. Oral dronabinol 2.5 mg twice daily
B. Oral megestrol 400 mg/d
C. Placement of gastrostomy tube for enteral feedings
D. Total parenteral nutrition
E. Small meals of the patient’s favorite foods
57
CASE 3 (3 of 3)
Which one of the following is the most appropriate
recommendation for this patient?
A. Oral dronabinol 2.5 mg twice daily
B. Oral megestrol 400 mg/d
C. Placement of gastrostomy tube for enteral feedings
D. Total parenteral nutrition
E. Small meals of the patient’s favorite foods
58
GRS9 Slides Editor:
Mandi Sehgal, MD
GRS9 Chapter Authors:
Grace A. Cordts, MD, MPH, MS
Danielle J. Doberman, MD, MPH
GRS9 Question Writer:
Susan Charette, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society