Anorexia (lack of appetite) is prevalent in advanced cancer and in many advanced chronic illnesses.82 For patients who die over a prolonged period of time, anorexia usually occurs in the last weeks to days of life. In the terminal phase lack of appetite is often the first in a series of normal losses. (See Chapter 11 on the final 48 hours.) In earlier phases care must be taken to rule out reversible causes of anorexia, such as mouth infections, dysgeusia (abnormal taste) related to chemotherapy or zinc deficiency, pain, nausea, and, depression.83
What is the suffering in the loss of appetite? Loss of appetite represents the loss of a pleasurable experience, eating. This loss of a primordial pleasure usually results in a grief reaction. Families grieve the loss of the ability to nurture, and patients grieve the loss of being nurtured in this most basic of ways. Understanding the nature of these losses helps caregivers to work with patients and families beyond simply trying to improve appetite. Families may need to be coached in how to nurture without measuring nurturing in terms of the amount consumed. A favorite ice cream or pudding would likely be more refreshing for the patient than would a three-course meal. Similarly, patients can be encouraged to "indulge" by eating small amounts of favored foods simply for the pleasure of taste.
Cancer and HIV have been most studied in terms of appetite stimulants. Less is known about appetite stimulation in other diseases. A variety of agents have been tried.84 The best-known are megestrol, dronabinol, and steroids. It is important to separate the effects of these drugs on appetite from their effects on building lean body mass and improving functional status. In cancer, at least, the major effect of all these agents is on appetite. If present at all in cancer, weight gain, especially with megestrol and steroids, reflects either water or fat gain, not a gain in lean body mass.85,86 In cancer appetite stimulation is just that - appetite stimulation - not a method of overriding cancer-related cachexia. All three agents have been found to be effective in series of patients. Megestrol must be given in high doses, approximately 800 mg a day. It is generally well tolerated. Dronabinol, a tetra hydro cannabinol (THC) derivative, may also be effective. It has been best studied in HIV, in which a placebo-controlled trial demonstrated improved appetite.87 It may be associated with mental status changes, which may be welcomed or disturbing. Steroids, such as dexamethasone, are effective appetite stimulants. Dexamethasone is also a useful adjuvant in pain management and as an anti-inflammatory. Dexamethasone is most helpful in the terminal phase of illness, the last few weeks to months of life. If used before this stage for appetite stimulation, side effects such as immunosuppression, steroid-related myopathy, and osteoporosis may result in burdens that outweigh the benefits.
At some point even those patients who initially respond to appetite stimulants will lose their appetite. Unless the appetite stimulating medication, such as dexamethasone, is being given for another purpose, there is no medical benefit in continuing such therapy. Patients and families may resist efforts to discontinue therapy out of grief - giving up the medication may mean acknowledging progression of illness and another loss in a series of losses. Careful explanation and attention to the grief reaction that usually accompanies such discontinuation is important.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.