General management of anorexia, weight loss and cachexia in palliative care

Management of anorexia, weight loss and cachexia is guided by potential benefits and burdens of each intervention, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care.

For patients with palliative care needs who are expected to live long enough to see the benefits and are able to engage in treatment, a multidisciplinary, multimodal approach to managing anorexia, weight loss and cachexia is beneficial and can improve quality of life—refer these patients to a specialist clinic. Cachexia is a progressive syndrome; at a certain point it becomes irreversible, and the focus should then be on comfort measures.

Avoid measuring weight in patients with established cachexia and more advanced disease who have a shorter prognosis (weeks to months). Most patients and their carers know they are losing weight without their awareness being heightened by ongoing measurements.

Identify and treat causes of anorexia and weight loss if possible. Optimise management of swallowing difficulties and mucositis.

Present food in small servings, on appropriately sized plates (eg a bread and butter plate); it is more satisfying to finish a small plateful than to eat a few mouthfuls of a large meal. Whenever possible, present food in a socially normal situation. For example, if there is a strong tradition of a family eating together, then provide meals for the patient when and where others can also eat. Patient preference should be the guide for all meals, focusing on enjoyment of the taste of food rather than on quantity or balance of nutrition. Avoid strong cooking smells, which are a common trigger for nausea.

Pureed food may be useful for patients with swallowing difficulties. If the patient wants to eat but has difficulty doing so, a dietitian can suggest strategies to improve the quality of food. Patients with a life-limiting illness may enjoy protein supplement drinks, which can be given instead of meals.

For patients with cachexia, treat symptoms, including nausea and vomiting, constipation, pain and depression. The effect of cachexia on chest wall muscles is often under-recognised and may affect accessory respiratory muscles, precipitating or contributing to breathlessness and respiratory failure.

Neither enteral nor parenteral nutrition decrease weight loss or improve lethargy or survival for patients who are in the last days of life, and their use can impair quality of life. There is a risk of systemic infection and thrombosis arising from intravenous catheters. The provision of enteral or parenteral nutrition may also shift the focus from the patient to the treatment. See Nutrition and hydration in the last days of life for discussion of nutrition at the end of life.