Abstract

Objective

To analyze the nutritional interventions adopted in older people in palliative care found in the literature.

Method

A scoping review was conducted involving a search of the following databases: PubMed, LILACS, CINAHL, Scopus, Web of Science, EMBASE and of the gray literature through Google Scholar, OpenGrey and ProQuests & Theses Global, without restrictions on publication date or language. The searches were performed using the descriptors and keywords, combined using Boolean operators AND and OR: “Nutritional Intervention”, “Intervenção Nutricional”, “Palliative Care”, “Cuidados Paliativos”, “Aged” and “Idosos”.

Results

Of the 5,942 studies found, 13 studies were selected. The backward citation search strategy identified 13 additional studies, giving a final total of 26 studies. Nutritional interventions adopted in older people in palliative care predominantly comprised nutritional counseling, oral nutritional supplementation and artificial nutrition through enteral and parenteral nutrition. These interventions focused on quality of life, symptom management and nutritional status.

Conclusion

Although there are gaps in the literature regarding nutritional interventions for older adults in palliative care, the importance of the role of nutritionists in promoting quality of life and relieving suffering of this population is clear.

Keywords
Palliative Care; Nutrition Therapy; Aged; Nutritionists

Resumo

Objetivo

Analisar as intervenções nutricionais adotadas em pessoas idosas em cuidados paliativos encontradas na literatura.

Método

Trata-se de uma revisão de escopo, cuja busca foi realizada nas seguintes bases de dados: PubMed, LILACS, CINAHL, Scopus, Web of Science, EMBASE e na literatura cinzenta por meio do Google Scholar, OpenGrey e ProQuest Dissertations & Theses Global, sem restrição temporal e de idioma. Foram realizadas as buscas utilizando-se os descritores e palavras-chave que foram combinados por meio de operadores booleanos AND e OR: “Nutritional Intervention”, “Intervenção Nutricional”, “Palliative Care”, “Cuidados Paliativos”, “Aged” e “Idosos”.

Resultados

Dos 5.942 estudos encontrados, 13 estudos foram selecionados. Pela estratégia de busca reversa foram identificados 13 estudos adicionais, originando um resultado final de 26 estudos. As intervenções nutricionais adotadas em pessoas idosas em cuidados paliativos compreendem em sua maioria: aconselhamento nutricional, suplementação nutricional oral e a nutrição artificial por meio de nutrição enteral e parenteral. Essas intervenções estão voltadas à qualidade de vida, ao manejo de sintomas e ao estado nutricional.

Conclusão

Embora haja lacunas na literatura quanto às intervenções nutricionais voltadas para idosos em cuidados paliativos, fica evidenciada a importância da atuação do nutricionista para promoção da qualidade de vida e alívio do sofrimento dessa população.

Palavras-Chave:
Cuidados Paliativos; Terapia Nutricional; Idoso; Nutricionistas

INTRODUCTION

The natural course of human aging is accompanied by a greater susceptibility for developing diseases such as cancer, neurologic disorders and chronic musculoskeletal conditions, among others¹1 Howlett SE, Rutenberg AD, Rockwood K. The degree of frailty as a translational measure of health in aging. Nat Aging. 2021;1(8):651–665. Disponível em: http://dx.doi.org/10.1038/s43587-021-00099-3
https://doi.org/10.1038/s43587-021-00099... . These diseases can result in progressive impairment that can lead to functional dependence which, together with declining health status, may require palliative care²2 Moura, RBB; Araújo, AA; Barbosa, JM; Araújo R. Estado nutricional e funcionalidade em idosos hospitalizados em hospital universitário. Acta Port Nutr. 2020;21:22–25. Disponível em: https://actaportuguesadenutricao.pt/wp-content/uploads/2020/08/05_ARTIGO-ORIGINAL.pdf.

Palliative care can be defined as holistic care provided actively to individuals of any age who are suffering from serious diseases, especially those with a terminal illness, aimed at improving quality of life of the patient, family members and caregivers²2 Moura, RBB; Araújo, AA; Barbosa, JM; Araújo R. Estado nutricional e funcionalidade em idosos hospitalizados em hospital universitário. Acta Port Nutr. 2020;21:22–25. Disponível em: https://actaportuguesadenutricao.pt/wp-content/uploads/2020/08/05_ARTIGO-ORIGINAL.pdf.

In this context, a multidisciplinary team is needed for the delivery of palliative care to the older patient, delivering care which takes the individual as a whole into account, assessing all dimensions and devising an effective approach that encompasses all aspects evaluated. Among the different professionals involved in the team, the nutritionist must seek the best strategies for management of patient nutrition, ensuring adequate food intake based on physical, psychological and religious dimensions, all of which influence improvement in the quality of life of patients⁴4 Taberna M, Gil Moncayo F, Jané-Salas E, et al. The Multidisciplinary Team (MDT) Approach and Quality of Care. Front Oncol. 2020;10(March):1–16. Disponível em: https://www.frontiersin.org/article/10.3389/fonc.2020.00085/full.

The role of the nutritionist entails interventions which can both help maintain or restore nutritional status, as well as promote well-being during the different stages of disease. The goals of nutritional support, as end-of-life approaches, should center more on improving quality of life than achieving adequate nutrition. Thus, nutritional interventions should be reconciled with the aim of palliative care in providing comfort and helping control symptoms⁵5 Moura, RBB; Melo, ABP; Chaves, TR; Vaz, LMM; Barbosa, JM; Araújo R. Condutas para o Manejo da Anorexia em Cuidados Paliativos : Revisão Integrativa. Rev Fun Care Online. 2020. jan./dez.; 12:737-743. DOI: http://dx.doi.org/10.9789/2175-5361.rpcfo.v12.9432
https://doi.org/10.9789/2175-5361.rpcfo.... ,⁶6 Amorim GKD, Silva GSN da. Nutricionistas e cuidados paliativos no fim de vida: revisão integrativa. Rev Bioética. 2021;29(3):547–557. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-80422021000300547&tlng=pt.

Concerns over defining adequate procedures and strategies to cater for the nutritional needs of older patients in palliative care remains a source of discussion among nutritionists, given that many professionals are ill-prepared to deal with situations in practice that stray outside conventional text-book situations⁶6 Amorim GKD, Silva GSN da. Nutricionistas e cuidados paliativos no fim de vida: revisão integrativa. Rev Bioética. 2021;29(3):547–557. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-80422021000300547&tlng=pt , highlighting the importance of further studies on this topic that can help support these professionals in their professional practice. A search of the Cochrane database and Open Science Framework (OSF) and PROSPERO - International Prospective Register of Ongoing Systematic Reviews platforms found no similar reviews involving this population, underscoring the need for further studies in this area. Therefore, the objective of the present scoping review was to analyze the available scientific evidence on nutritional interventions adoption in older adults in palliative care to help guide nutritionists who work clinically with this population.

METHOD

A scoping review was conducted according to the review method of the Joanna Briggs Institute (JBI)⁷7 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–473. Disponível em: https://www.acpjournals.org/doi/10.7326/M18-0850, using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines⁸8 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Ver. 2016;5(1):210. Disponível em: http://dx.doi.org/10.1186/s13643-016-0384-4
https://doi.org/10.1186/s13643-016-0384-... . A protocol was developed and registered on the Open Science Framework (https://osf.io/) platform under DOI: 10.17605/OSF.IO/ECT8K (https://osf.io/ect8k). The databases searched were: Medline/PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and LILACS. The search of the gray literature was carried out using Google Scholar, OpenGrey and ProQuest Dissertations & Theses Global. The backward citation search strategy was employed by consulting all references of the articles selected for inclusion in the review.

The PCC (Population, Concept and Context) strategy was used, with population defined as older adults, concept as nutritional interventions, and context as palliative care. The following guiding research question was devised: what nutritional interventions are adopted for older adults in palliative care?

Based on application of the PCC strategy, the descriptors present in the MeSH (Medical Subject Headings) and the DeCS (Descritores em Ciências da Saúde- Health Science Descriptors) were selected: “nutritional intervention”, “intervenção nutricional”, “palliative care”, “cuidados paliativos”, “aged” and “idosos”, together with their synonyms, combined using the Boolean operators (OR e AND) and adapted for each database. The full detailed strategy is available in the supplementary file containing the scoping review design via the link: https://osf.io/e6q4x/?view_only=897c5461698c48f6abe0d03ba310ac24

The process of devising the search and refinement strategy was overseen by a librarian.

The search encompassed all intervention and observational studies, with no constraints on language or search period, that assessed nutritional approaches in older adults in palliative care. Studies were excluded that did not include participants age ≥60 years; studies in which participants did not undergo nutritional intervention; reviews; abstracts; opinion articles; case reports; case series and book chapters.

After the searches, all records retrieved were exported to the EndNote reference manager, where they were grouped for automatic removal of duplicate articles. The studies were exported to the Rayaan⁹9 Peters MDJ, Godfrey MC, Mcinerney P, Soares CB, Khalil H PD. The Joanna Briggs Institute Reviewers’ Manual 2015: Methodology for JBI scoping reviews. Joanne Briggs Inst 2015;(February 2016):1–24. software application, where refinement of duplicate articles took place, followed by a two-stage study selection procedure.

In the two stages, 2 independent reviewers (RBBM and JMB) performed screening (reading of titles and abstracts) and reading of full texts. Any differences between the reviewers were resolved by consensus or by decision of a third reviewer (MCRG), while applying the inclusion criteria pre-defined in the protocol.

For data extraction, the reviewers created a form collecting the following information: study characteristics (authors, year of publication, country and study design), population characteristics (sample size, mean age), characteristics of signs and symptoms reported, intervention characteristics, primary and secondary outcomes, and conclusions on intervention effects.

The data were analyzed using quantitative description, expressing results as absolute and relative frequencies, and qualitative analysis was performed using theme-based categories regarding intervention effects for 3 aspects: quality of life, symptoms control and nutritional status.

In the present study, no rating of study quality or level of scientific evidence was conducted as criteria for exclusion of articles, given that, according to guidelines of the Joanna Briggs Institute for scoping reviews⁷7 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–473. Disponível em: https://www.acpjournals.org/doi/10.7326/M18-0850, there is no need to assess specific quality because this type of study aims to identify the available output on the topic investigated. Ethical approval was also waived, in accordance with Resolution Nº 466/2012 and Nº 510/2016 governing research ethics in Brazil.

RESULTS

An initial total of 5,942 studies were retrieved from the databases and gray literature. After removal of duplicates, 3,666 studies remained. Screening was performed by reading of titles and abstracts, where 37 articles were selected for the second stage. After reading of articles in full, 13 studies that met the eligibility criteria were selected. The backward citation search led to the selection of a further 13 articles, giving a total of 26 articles included in the review. Figure 1 depicts a flow chart showing the study selection process.

The studies included were performed on different continents, with 53.9% conducted in Europe, 23.1% in North America, 11.5% in Asia and 11.5% in Oceania, and were published between 1979 and 2021.

The study design methods were distributed as follows: Randomized Clinical Trial (RCT) 42.3%, Quasi-Experimental (QE) 26.9%, Prospective Longitudinal Cohort (PLC) 23.1%, and Retrospective Cohort (RC) 7.7%.

The characteristics of studies selected are described in Table 1.

In order to organize the results in terms of the study objectives, the main interventions and their effects were summarized and associations with 3 aspects presented: Interventions and effects on Quality of Life (Table 2), Interventions and effects on Symptoms Control (Table 3), and Interventions and effects on Nutritional Status (Table 4).

Interventions and effects on quality of life

In the overall sample, 13 studies addressed nutritional interventions adopted for promoting quality of life¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8,¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export,¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8–²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4. The most frequent interventions were nutritional counseling, use of oral nutritional supplementation and home parenteral nutritional support¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live reporting benefits with the use of these interventions.

A multimodal intervention, which included physical activity, nutrition and symptoms control in palliative care, was adopted in one study²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8, appearing to be beneficial and safe in promoting quality of life in advanced lung cancer patients. However, owing to the study design lacking a control group, further studies exploring this type of intervention are needed.

The use of percutaneous endoscopic gastronomy (PEG) in patients with malignant bowel obstruction promoted improved quality of life compared with the use of nasogastric (NG) tube, with no serious adverse events and fewer complication reported in the PEG group¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8..

Only one study addressed the use of protein and energy supplements enriched with omega 3 fatty acid, promoting positive outcomes for quality of life. However, further more in-depth studies examining the potential of these supplements in the treatment of cancer cachexia are required²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479..

One of the studies investigated individual nutritional support as a protection strategy in post-stroke patients at nutritional risk, using an individual nutritional treatment plan, via the oral route, or feeding tube in the case of dysphagic patients. This strategy was associated with improved quality of life²⁴24 Ha L, Hauge T, Spenning AB, Iversen PO. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: A randomized, controlled trial. Clin Nutr. 2010;29(5):567–573. Disponível em: http://dx.doi.org/10.1016/j.clnu.2010.01.011
https://doi.org/10.1016/j.clnu.2010.01.0... .

Regarding impacts of nutritional counseling and use of oral nutritional supplementation on quality of life, of the 4 studies¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live involving this type of intervention, only 1 reported no effect on quality of life, in advanced cancer patients receiving chemotherapy¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live..

Interventions and effects on symptoms control

Of the total sample, 11 studies addressed the effects of the interventions on the control of different symptoms¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹¹11 Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med 2009;23(8):680–688.,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁹19 Crogan NL. Relieving Drug-Induced Xerostomia With Sorbet. Ann Long Term Care. 2015;23(2):17–21. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107777911⟨=pt-br&site=ehost-live,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8,²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,³⁰30 Mccann RM, Hall WJ, Groth Juncker A. Comfort Care for Terminally III Patients: The Appropriate Use of Nutrition and Hydration. JAMA J Am Med Assoc. 1994;272(16):1263–1266. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0028110449&doi=10.1001%2Fjama.1994.03520160047041&partnerID=40&md5=01876a8736d40dd7635c3239019d3c4c–³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221, as presented in Table 3.

One study observed that the prevalence of bedsores, edema and the use of antibiotic was attenuated by individual nutritional support, which included nutritional counseling, the use of oral nutritional supplements and total parenteral nutrition, when necessary¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273. Individual nutritional support was also effective for improving protein-energy intake of cancer patients in 2 of the studies reviewed²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,³¹31 Persson CR, Johansson BBK, Sjoden P-O, Glimelius BLG. A Randomized Study of Nutritional Support in Patients With Colorectal and Gastric Cancer. Nutr Cancer. 2002;42(1):48–58. Disponível em: http://www.tandfonline.com/doi/abs/10.1207/S15327914NC421_7, while another study found improved protein-energy intake with the use of nutritional counseling and oral nutritional supplementation compared to standard practice²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745.

Nutritional counseling was the intervention which promoted positive effects on the highest number of symptoms, namely: digestive symptoms, fatigue, dyspnea, poor appetite, protein-energy intake, anorexia, nausea/vomiting, xerostomia and dysgeusia¹¹11 Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med 2009;23(8):680–688.,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live. Two articles investigated the positive effect of nutritional counseling with the concomitant use of oral nutritional supplement²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221.

Xerostomia was significantly relieved with the use of sugar-free lime-lemon sorbet prior to 2 daily meals¹⁹19 Crogan NL. Relieving Drug-Induced Xerostomia With Sorbet. Ann Long Term Care. 2015;23(2):17–21. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107777911⟨=pt-br&site=ehost-live. A positive outcome was also achieved using small amounts of liquids, foods and/or icechips, which also helped reduce discomfort, hunger and thirst³⁰30 Mccann RM, Hall WJ, Groth Juncker A. Comfort Care for Terminally III Patients: The Appropriate Use of Nutrition and Hydration. JAMA J Am Med Assoc. 1994;272(16):1263–1266. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0028110449&doi=10.1001%2Fjama.1994.03520160047041&partnerID=40&md5=01876a8736d40dd7635c3239019d3c4c.

A multimodal intervention involving palliative physical activity, nutrition and symptoms control appeared to be beneficial for reducing fatigue symptoms in advanced lung cancer patients, but further studies are needed for more robust conclusions²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8.

Interventions and effects on nutritional status

A total of 17 studies involved interventions to improve nutritional status¹³13 Arnold C, Richter MP. The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol. 1989;16(6):1595–1599. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/0360301689909681,¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³¹31 Persson CR, Johansson BBK, Sjoden P-O, Glimelius BLG. A Randomized Study of Nutritional Support in Patients With Colorectal and Gastric Cancer. Nutr Cancer. 2002;42(1):48–58. Disponível em: http://www.tandfonline.com/doi/abs/10.1207/S15327914NC421_7–³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654,¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479–²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47. Five of these reported improvement in nutritional status following nutritional counseling¹³13 Arnold C, Richter MP. The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol. 1989;16(6):1595–1599. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/0360301689909681,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live. This intervention promoted a positive outcome which was superior to the use of oral nutritional supplement alone³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221, in addition to significant improvements in weight gain of cancer patientsr²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.. A randomized clinical trial¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live was the only study that failed to show efficacy of this type of intervention on nutritional status of patients with cancer and weight loss receiving chemotherapy. However, the study was suspended early upon recommendation of a data monitoring committee.

With regard to the use of omega-3 fatty acid enriched supplements, those studies which administered this intervention had conflicting results¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654,²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479. One of the studies showed positive results for weight gain, with a significant improvement in appetite after 3 weeks¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654.. Another study compared the effect of antioxidant and omega-3 enriched supplements with a standard supplement on nutritional status over an 8-week period. It was concluded that the study failed to address the hypothesis developed from pilot data, with further studies needed to confirm the potential efficacy of the use of omega-3 enriched supplements in cancer cachexia²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479.

Artificial nutrition and its efficacy for improving nutritional status of palliative patients was assessed by 7 of the studies reviewed¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47–²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... ,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108. Results showed that when intake of a regular diet complemented with oligomer supplement was possible, serum albumin was better preserved¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5.

With regard to the use of enteral nutrition, the findings showed that this can serve as a palliative treatment for undernutrition, albeit with limited effect, with this approach being more indicated for patients with regular functional capacity, no intense pain symptoms or neurological disorders²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47. When use of enteral nutrition is indicated, special silicon tubes provide greater comfort for patients¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5.

The use of total parenteral nutrition for improving nutritional status was addressed in 6 of the studies selected¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... ,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108. One of these investigations noted the intervention may be reserved for certain stages, particularly the pre-operative stage, and also more critical stages of care for supporting primary surgery, chemotherapy or radiotherapy for cancer¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5. Another study concluded that home parenteral nutrition can prevent death due to undernutrition in 73% of cases³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... . A 2015 study found improved weight gain in 63% of older adults with cancer³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108, while another study, published in 2010, found a positive impact on both nutritional status and quality of life in malnourished patients receiving salvage chemotherapy treatment²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4.

An RCT documented a significant increase in body fat over time in older cancer patients, but no difference in muscle mass between the groups was evident²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export. Similarly, a prospective observational study found that home parenteral nutrition was associated with improved nutritional status in cancer patients, recommending that an RCT be conducted to provide more solid conclusions²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9.

Also, a study involving older stroke patients at nutritional risk observed that individual nutritional support can protect against malnutrition²⁴24 Ha L, Hauge T, Spenning AB, Iversen PO. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: A randomized, controlled trial. Clin Nutr. 2010;29(5):567–573. Disponível em: http://dx.doi.org/10.1016/j.clnu.2010.01.011
https://doi.org/10.1016/j.clnu.2010.01.0... .

DISCUSSION

In the sample selected, nutritional counseling, in association with use of nutritional supplementation or otherwise, was the most commonly adopted intervention among the 3 aspects evaluated: quality of life, symptoms control and nutritional status¹¹11 Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med 2009;23(8):680–688.,¹³13 Arnold C, Richter MP. The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol. 1989;16(6):1595–1599. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/0360301689909681,¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,²⁵25 Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91(3):447–452. Disponível em: http://www.nature.com/articles/6601962,²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live.This intervention provided patients with guidance on the amount and frequency of meals, fortifying of foods, changes in consistency, according to current clinical condition and symptoms present, as well as family support and a pleasant environment for meals, where good communication was key to achieving more successful outcomes³⁶36 Childs DS, Jatoi A. A hunger for hunger: a review of palliative therapies for cancer-associated anorexia. Ann Palliat Med. 2019;8(1):50–58.. This finding corroborates the European Society of Parenteral and Enteral Nutrition guidelines (ESPEN) guidelines³⁷37 Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48. recommending that, for radiotherapy patients, nutritional intake should be underpinned mainly by individual nutritional counseling and/or with the use of oral nutritional supplements, improving nutritional intake, body weight and quality of life, benefitting patients and preventing interruptions in treatment³⁷37 Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48..

Concerning survival and response to treatment, although there is often no positive impact, in some studies³⁶36 Childs DS, Jatoi A. A hunger for hunger: a review of palliative therapies for cancer-associated anorexia. Ann Palliat Med. 2019;8(1):50–58.,³⁸38 Hagmann C, Cramer A, Kestenbaum A, et al. Evidence-based palliative care approaches to non-pain physical symptom management in cancer patients. Semin Oncol Nurs. 2018;34(3):227–240., nutritional counseling is recommended given that many patients report greater benefits for health and general well-being than individuals not receiving counseling. This highlights the importance of the role of the nutritionist, committed to providing, on an individual level, the guidance and recommendations needed to promote well-being and comfort of these patients³⁶36 Childs DS, Jatoi A. A hunger for hunger: a review of palliative therapies for cancer-associated anorexia. Ann Palliat Med. 2019;8(1):50–58.,³⁸38 Hagmann C, Cramer A, Kestenbaum A, et al. Evidence-based palliative care approaches to non-pain physical symptom management in cancer patients. Semin Oncol Nurs. 2018;34(3):227–240..

The literature shows that, with regard to indication of artificial nutrition in older adults in palliative care, contradictions exist over its true risks and benefits³⁹39 Castro JMF de, Frangella VS, Hamada MT. Consensos e dissensos na indicação e continuidade da terapia nutricional enteral nos cuidados paliativos de pacientes com doenças crônicas não transmissíveis. ABCS Heal Sci. 2017;42(1):519–522.. In the present review, 11 studies ¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108,¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export–¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47–²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... addressing this intervention were found, particularly the use of home parenteral nutritional support¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... .

With regard to quality of life, only the study by Bouleuc et al.¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export, of the 11 studies¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export–¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47–²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... ,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108 on parenteral nutrition reviewed, reported negative quality of life outcomes for use of total parenteral nutrition in malnourished advanced cancer patients, noting more severe side-effects. Thus, the authors did not recommend prescribing parenteral nutrition for advanced cancer patients with a life expectancy of less than 3 months.

The ESPEN guidelines on clinical nutrition and hydration in geriatrics⁴⁰40 Volkert D, Beck AM, Cederholm T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr. 2018;38(1):10–47. Disponível em: https://doi.org/10.1016/j.clnu.2018.05.024
https://doi.org/10.1016/j.clnu.2018.05.0... recommend that artificial nutrition be considered as a clinical treatment rather than basic care and, hence, should be used only in cases of a realistic chance of improvement or maintenance of the patient´s quality of life. Ratifying this guidance, the practical guidelines for clinical nutrition in cancer of the Brazilian Society of Parenteral and Enteral Nutrition (BRASPEN)⁴¹41 Horie LM, Ana Paula Noronha Barrére, Castro MG, et al. Diretriz Braspen de terapia nutricional no paciente com câncer e Braspen recomenda: Indicadores de qualidade em terapia nutricional. Braspen J 2019;34(Supl 1):41–49., and also of the ESPEN⁴²42 Muscaritoli M, Arends J, Bachmann P, et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr. 2021;40(5):2898–2913. Disponível em: https://doi.org/10.1016/j.clnu.2021.02.005
https://doi.org/10.1016/j.clnu.2021.02.0... , carry a similar recommendation, stating that the benefit of nutritional support for advanced cancer patients in palliative care should be considered carefully, taking into account both the patient prognosis and survival. Patients with a good prognosis and expected overall survival of at least a few months, as well as patients with low tumor activity and no inflammatory reaction, should receive adequate counseling and nutritional support, including oral, enteral or, if necessary, parenteral nutrition or a combination of these approaches. There is little or no benefit of nutritional support in the last weeks of life, given this will result in no functional or comfort benefit for the patient⁴¹41 Horie LM, Ana Paula Noronha Barrére, Castro MG, et al. Diretriz Braspen de terapia nutricional no paciente com câncer e Braspen recomenda: Indicadores de qualidade em terapia nutricional. Braspen J 2019;34(Supl 1):41–49.,⁴²42 Muscaritoli M, Arends J, Bachmann P, et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr. 2021;40(5):2898–2913. Disponível em: https://doi.org/10.1016/j.clnu.2021.02.005
https://doi.org/10.1016/j.clnu.2021.02.0... .

Six of the studies¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... ,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108 reviewed showed benefits of home artificial nutrition for quality of life and nutritional status. Similarly, Orrevall et al.⁴³43 Orrevall Y, Tishelman C, Permert J, Lundström S. A national observational study of the prevalence and use of enteral tube feeding, parenteral nutrition and intravenous glucose in cancer patients enrolled in specialized palliative care. Nutrients. 2012;5(1):267–282. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L368277971& from=export concluded that patients with cancer and intake and nutrient absorption deficits can be indicated home artificial nutritional support, even at advances stages of the disease, provided survival is longer than a few weeks. This benefit is evident from the extended survival of months or years seen in cancer patients receiving exclusively parenteral nutrition, patients which without feeding would have otherwise died⁴⁴44 Bozzetti F. Nutritional support of the oncology patient. Crit Rev Oncol Hematol. 2013;87(2):172–200. Disponível em: http://dx.doi.org/10.1016/j.critrevonc.2013.03.006
https://doi.org/10.1016/j.critrevonc.201... .

For use of home artificial nutrition, careful patient selection is recommended, with eligible candidates presenting chronic insufficient dietary intake and/or uncontrollable poor absorption³⁷37 Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48.. Home parenteral nutrition is a complex therapy, requiring proper screening of patients for this type of treatment. Assessment of cognitive and physical abilities of the patent prior to embarking on the training program is fundamental. In addition, the home environment, clinical suitability, potential for rehabilitation, social and economic factors and sources of financing, should also be assessed by the multidisciplinary team before commencement of training for home parenteral nutrition⁴⁵45 Pironi L, Boeykens K, Bozzetti F, et al. ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020;39(6):1645–1666. Disponível em: https://doi.org/10.1016/j.clnu.2020.03.005
https://doi.org/10.1016/j.clnu.2020.03.0... .

Regarding nutritional status, only one²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47 of the 4 studies¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8,¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... addressing enteral nutrition reviewed showed a limited effect of this nutritional support, which should be considered only in patients with regular functional capacity and absence of debilitating symptoms. In cancer patients, to prevent or treat malnutrition, the ESPEN guidelines recommend the use of enteral nutrition if oral nutrition is inadequate, despite the use of counseling nutritional intervention and oral nutritional supplementation, and recommend parenteral nutrition in cases where enteral nutrition proves insufficient or not possible³⁷37 Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48..

In patients with a poor prognosis and life expectancy of just weeks or days, the literature stresses the importance of considering bioethical aspects of feeding, particularly with respect to religious, cultural and ethnic aspects, and also social, emotional and existential dimensions³⁷37 Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11–48.. Complementing this aspect, the study of Cardenas⁴⁶46 Cardenas D. Ethical issues and dilemmas in artificial nutrition and hydration. Clin Nutr ESPEN. 2021;41:23–29. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85098662397&doi =10.1016%2Fj.clnesp.2020.12.010&partnerID=40&md5= 6ac8d2555310bd1276382fe6c3be0cae, examined, as one of the special situations, nutritional therapy and hydration in older individuals, given that this population is at greater risk of developing malnutrition due to multiple comorbidities and associated polypharmacy. Nevertheless, the indication of artificial nutrition should be reviewed at regular intervals, weighing the risks and benefits, while respecting the principles of beneficence, non-maleficence and autonomy⁴⁶46 Cardenas D. Ethical issues and dilemmas in artificial nutrition and hydration. Clin Nutr ESPEN. 2021;41:23–29. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85098662397&doi =10.1016%2Fj.clnesp.2020.12.010&partnerID=40&md5= 6ac8d2555310bd1276382fe6c3be0cae.

Another important finding of this review is the highlighting of some important strategies for the management of symptoms commonly shared by older patients in palliative care, such as xerostomia, dysgeusia, fatigue, dyspnea, poor appetite, anorexia, bedsores, edema, nausea and vomiting, with positive outcomes in all studies¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹¹11 Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med 2009;23(8):680–688.,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁹19 Crogan NL. Relieving Drug-Induced Xerostomia With Sorbet. Ann Long Term Care. 2015;23(2):17–21. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107777911⟨=pt-br&site=ehost-live,²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8,²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,³⁰30 Mccann RM, Hall WJ, Groth Juncker A. Comfort Care for Terminally III Patients: The Appropriate Use of Nutrition and Hydration. JAMA J Am Med Assoc. 1994;272(16):1263–1266. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0028110449&doi=10.1001%2Fjama.1994.03520160047041&partnerID=40&md5=01876a8736d40dd7635c3239019d3c4c–³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221 addressing this management, where nutritional counseling emerged as the most used intervention for symptoms relief.. Consistent with these findings, Pinho-Reis⁴⁷47 Pinho-Reis C. Suporte Nutricional em Cuidados Paliativos. Rev Nutrícias 2012;(15):24–27. described the management of many of these symptoms, using nutritional counseling strategies, while also addressing the need for changing feeding routes⁴⁷47 Pinho-Reis C. Suporte Nutricional em Cuidados Paliativos. Rev Nutrícias 2012;(15):24–27..

Nutritional care in the context of managing symptoms encompasses different interventions, including for instance nutritional counseling, enriching meals, provision of snacks, changing consistencies, administration of oral nutritional supplements, as well as enteral and parenteral nutrition, which can mutually complement one another in terms of their effects on the symptoms. However, nutritional care goes beyond interventions, also covering feeding assistance, adaptation of environmental factors and eliminating underlying causes, thus calling for multidisciplinary action involving nutritionists, nurses, helpers for general services, cooks, physicians, therapists, family members, caregivers and the patients themselves⁴⁰40 Volkert D, Beck AM, Cederholm T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr. 2018;38(1):10–47. Disponível em: https://doi.org/10.1016/j.clnu.2018.05.024
https://doi.org/10.1016/j.clnu.2018.05.0... .

Symptoms assessment in palliative care includes both objective and subjective components and requires the use of validated scales and tools available to guide professionals in assessing pain and other sources of suffering, e.g. the Edmonton Symptom Assessment Scale (ESAS), widely used in research of palliative care for its ease of use as a system or manually as a checklist⁴⁸48 National Consensus Project for Quality Palliative Care. Clin Pract Guidel Qual Palliat Care 2018;(4)..

Only 2 of the studies selected¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654,²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479 explored the use of omega 3 fatty acid. Of these, the study by Fearon et al.²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479 concluded that the study failed to demonstrate that use of supplements enriched with this nutraceutical compound promoted anabolism in patients with cachexia. However, analysis of the dose-response potential showed that, if used at sufficient quantity, this intervention promoted net weight and lean tissue gains and improved quality of life. The study by Leite et al.⁴⁹49 Leite JT de A, Lobo LC, Andrade LG de. Ômega-3 no tratamento paliativo do câncer. Rev Ibero-Americana Humanidades, Ciências e Educ. 2021;7(10):1547–1561. Disponível em: https://periodicorease.pro.br/rease/article/view/2680 showed several benefits of omega 3 supplementation in the promotion of quality of life of patients receiving cancer treatment, providing improvements in inflammatory and immunological response, muscle synthesis, xerostomia, healing of surgical wounds and cancer-induced cachexia. Similarly, the guidelines of the BRASPEN⁴¹41 Horie LM, Ana Paula Noronha Barrére, Castro MG, et al. Diretriz Braspen de terapia nutricional no paciente com câncer e Braspen recomenda: Indicadores de qualidade em terapia nutricional. Braspen J 2019;34(Supl 1):41–49. recommend omega-3 supplementation for patients on chemotherapy, who are malnourished, or experiencing weight loss, with the aim of establishing or enhancing appetite. This guideline, however, emphasizes that the evidence supporting the use of omega 3 remains inconclusive, requiring further studies to determine the ideal dose and timing for its use.

The present review has important implications for the practice of nutritionists, and also contributes to future studies. This is the case because the majority of nutritionists involved in palliative care, particularly end-of-life, are not specifically trained in palliative care, highlighting the tendency for therapeutic obstinacy, overlooking the distress caused by some interventions and failing to recognize the need to minimize ethical conflicts in decision-making⁵⁰50 Maingué PCPM, Sganzerla A, Guirro ÚB do P, Perini CC. Discussão bioética sobre o paciente em cuidados de fim de vida. Rev Bioética. 2020;28(1):135–146. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-80422020000100135&tlng=pt. This knowledge must be disseminated among nutritionists, with the exchange of experiences on care protocols used in each care setting designed for older patients in palliative care, guiding professional conduct in this area. It is also important to revisit spiritual aspects and the role of the nutritionist, toward performing a full holistic assessment.

Regarding design methodology of the studies, there were 11 RCTs¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8,¹⁴14 Baldwin C, Spiro A, McGough C, et al. Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial. J Hum Nutr Diet. 2011;24(5):431–440. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=104680515⟨=pt-br&site=ehost-live,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export,²³23 Fearon, KCH; Von Meyenfeldt, MF; Moses, AGH; Van Geenen, R; Roy, A; Gouma, DJ; Giacosa, A; Van Gossum, A; Bauer, J; Barber, MD; Aaronson, NK; Voss, AC; Tisdale M. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52(10):1479–1486. Disponível em: https://gut.bmj.com/lookup/doi/10.1136/gut.52.10.1479–²⁶26 Isenring EA, Bauer JD, Capra S. Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice. J Am Diet Assoc. 2007;107(3):404–412. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0002822306026745,²⁸28 Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E. Palliative Nutritional Intervention in Addition to Cyclooxygenase and Erythropoietin Treatment for Patients with Malignant Disease: Effects on Survival, Metabolism, and Function: A Randomized Prospective Study. Cancer. 2004;100(9):1967–1977. Disponível em: https://www.embase.com/search/results?subaction=viewrecord&id=L38529575& from=export,³¹31 Persson CR, Johansson BBK, Sjoden P-O, Glimelius BLG. A Randomized Study of Nutritional Support in Patients With Colorectal and Gastric Cancer. Nutr Cancer. 2002;42(1):48–58. Disponível em: http://www.tandfonline.com/doi/abs/10.1207/S15327914NC421_7,³²32 Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: A prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck. 2005;27(8):659–668. Disponível em: https://onlinelibrary.wiley.com/doi/10.1002/hed.20221 and 6 prospective longitudinal cohort studies¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹¹11 Andrew IM, Waterfield K, Hildreth AJ, Kirkpatrick G, Hawkins C. Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome. Palliat Med 2009;23(8):680–688.,¹³13 Arnold C, Richter MP. The effect of oral nutritional supplements on head and neck cancer. Int J Radiat Oncol. 1989;16(6):1595–1599. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/0360301689909681,¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115,¹⁹19 Crogan NL. Relieving Drug-Induced Xerostomia With Sorbet. Ann Long Term Care. 2015;23(2):17–21. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107777911⟨=pt-br&site=ehost-live,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4 involving nutritional interventions. There were also 7 quasi-experimental studies¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654,¹⁷17 Ching N, Grossi C, Zurawinsky H, et al. Nutritional Deficiencies and Nutritional Support Therapy in Geriatric Cancer Patients. J Am Geriatr Soc. 1979;27(11):491–494. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0018608047&doi=10.1111%2Fj.1532-5415.1979.tb01735.x&partnerID=40&md5= acfec2349ebadbcf52dcf1c9826a1cf5,²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47,³⁰30 Mccann RM, Hall WJ, Groth Juncker A. Comfort Care for Terminally III Patients: The Appropriate Use of Nutrition and Hydration. JAMA J Am Med Assoc. 1994;272(16):1263–1266. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0028110449&doi=10.1001%2Fjama.1994.03520160047041&partnerID=40&md5=01876a8736d40dd7635c3239019d3c4c,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108 and only 2 retrospective cohort studies²¹21 Fabbro E Del, Hui D, Dalal S, Dev R, Nooruddin ZI, Bruera E. Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 2011;14(9):1004–1008.,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... . Of the 26 studies reviewed, only 11 were published within the last 10 years¹⁰10 Amano K, Morita T, Baba M, et al. Effect of Nutritional Support on Terminally Ill Patients With Cancer in a Palliative Care Unit. Am J Hosp Palliat Med. 2012;30(7):730–733. Disponível em: http://journals.sagepub.com/doi/10.1177/1049909112469273,¹²12 Aramaki T, Arai Y, Takeuchi Y, et al. A randomized, controlled trial of the efficacy of percutaneous transesophageal gastro-tubing (PTEG) as palliative care for patients with malignant bowel obstruction: the JIVROSG0805 trial. Support Care Cancer. 2019;28(6):2563–2569. Disponível em: http://link.springer.com/10.1007/s00520-019-05066-8,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live,¹⁶16 Bouleuc C, Anota A, Cornet C, et al. Impact on Health-Related Quality of Life of Parenteral Nutrition for Patients with Advanced Cancer Cachexia: Results from a Randomized Controlled Trial. Oncologist. 2020;25(5):e843–e851. Disponível em: https://www.embase.com/search/results? subaction=viewrecord&id=L2004547347&from=export,¹⁸18 Cotogni P, Carli L De, Passera R, et al. Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition. Cancer Med. 2017;6(7):1799–1806. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85019692432&doi=10.1002%2Fcam4.1111&partnerID=40&md5=1a0285036bb2c23aa0f29b86c9c07115–²⁰20 Culine S, Chambrier C, Tadmouri A, et al. Home parenteral nutrition improves quality of life and nutritional status in patients with cancer: a French observational multicentre study. Support Care Cancer. 2014;22(7):1867–1874. Disponível em: http://link.springer.com/10.1007/s00520-014-2164-9,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8,²⁹29 Ma C-J, Huang C-W, Yeh Y-S, et al. Supplemental home parenteral nutrition improved nutrition status with comparable quality of life in malnourished unresectable/metastatic gastric cancer receiving salvage chemotherapy. Support Care Cancer. 2020;29(4):1977–1988. Disponível em: https://link.springer.com/10.1007/s00520-020-05687-4,³³33 Ruggeri E, Giannantonio M, Agostini F, Ostan R, Pironi L, Pannuti R. Home artificial nutrition in palliative care cancer patients: Impact on survival and performance status. Clin Nutr. 2020;39(11):3346–3353. Disponível em: https://doi.org/10.1016/j.clnu.2020.02.021
https://doi.org/10.1016/j.clnu.2020.02.0... ,³⁴34 Senesse P, Tadmouri A, Culine S, et al. A Prospective Observational Study Assessing Home Parenteral Nutrition in Patients With Gastrointestinal Cancer: Benefits for Quality of Life. J Pain Symptom Manage. 2015;49(2):183-191.e2. Disponível em: https://linkinghub.elsevier.com/retrieve/pii/S0885392414003108, pointing to the need to carry out more multi-center studies with greater methodological rigor that can elucidate the most effective nutritional interventions in clinical practice for the older patient population in palliative care.

The present study has some limitations. Although mean age of participants of the studies was >60 years, most studies did not stratify results for the older adult age group, precluding analysis of specific data for this population. Six studies involved cohorts comprising 10-22 participants¹⁵15 Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81(1):80–86. Disponível em: http://www.nature.com/articles/6690654,¹⁹19 Crogan NL. Relieving Drug-Induced Xerostomia With Sorbet. Ann Long Term Care. 2015;23(2):17–21. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107777911⟨=pt-br&site=ehost-live,²²22 Ester M, Culos-Reed SN, Abdul-Razzak A, et al. Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer. 2021;21(1). Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85101427890&doi=10.1186%2Fs12885-021-07872-y&partnerID=40&md5=bb1ee1d61938539086e84886f0d404f8,²⁷27 Lindh A, Cedermark B, Blomgren H, Wasserman J, Petrini B. Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer. J Surg Oncol. 1986;33(1):61–65. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0022517615&doi=10.1002%2Fjso.2930330117&partnerID=40&md5=55e1af1dd5c9d9e8c4ab459fc5960e47,³⁰30 Mccann RM, Hall WJ, Groth Juncker A. Comfort Care for Terminally III Patients: The Appropriate Use of Nutrition and Hydration. JAMA J Am Med Assoc. 1994;272(16):1263–1266. Disponível em: https://www.scopus.com/inward/record.uri?eid=2-s2.0-0028110449&doi=10.1001%2Fjama.1994.03520160047041&partnerID=40&md5=01876a8736d40dd7635c3239019d3c4c,³⁵35 Silvers MA, Savva J, Huggins CE, Truby H, Haines T. Potential benefits of early nutritional intervention in adults with upper gastrointestinal cancer: a pilot randomised trial. Support Care Cancer. 2014;22(11):3035–3044. Disponível em: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=109758112⟨=pt-br&site=ehost-live, thereby limiting generalization of results. Concerning symptoms management in the studies reviewed, there was an absence of interventions involving symptoms common in the older population in palliative care, such as constipation, diarrhea and mucositis.

CONCLUSION

The present review mapped the main nutritional interventions adopted in older adults in palliative care. The findings highlight the need of knowledge by nutritionists on these interventions, and of further studies to build on this evidence.

Nutritional counseling was identified as providing best results across all aspects assessed, where nutritionists must be alert to the specific recommendations for patients to cater for the individual needs of each. Artificial nutrition was consistently reported as a means of promoting improvement in nutritional status and, consequently, in quality of life in the vast majority of the studies, requiring careful assessment of disease stage and life expectancy. Further studies should be carried out to elucidate the true contribution of omega 3 fatty acid to quality of life and nutritional status. Symptoms management should be conducted individually, with the goal of promoting comfort and relief according to patient needs. This requires a thorough evaluation of the intensity and type of symptoms presented, with interdisciplinary collaboration and using specific assessment tools. Although gaps in the literature on interventions adopted for older patients in palliative care exist, the vital role of the nutritionist in relieving suffering, promoting comfort and enhancing quality of life of this population is clear.

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