Home parenteral and enteral nutrition (HPEN) is a
viable and cost effective option for patients unable to maintain weight and
nutritional status through oral nutrient intake. HPEN may be short or long
term depending on the patient’s underlying cause for HPEN dependence. Catheter sepsis and other complications of parenteral nutrition are
controllable and can be held at reasonable levels with a well-trained team
approach.
The first study demonstrated that while HPEN-dependent
patients have to adjust to changes in sleep patterns and may make some
changes in social activities; their quality of life could be maintained for
a period of years. Physical functioning scores were expectedly lower than a
healthy population. However, mental function scores were similar to healthy
controls. No deaths were related to HPEN-related complications. Clinical
stability and underlying disease were the most significant factors in the
timing of death.
In many cases, the candidate for home parenteral
nutrition (HPN) starts out in a significantly malnourished state. The
effect of HPN in this population of patients was explored in the second
study finding mostly expected results of an initial improvement in weight,
fluid status, and fat tissues while lean tissue reconstitution lagged behind
in aggressive (but not over) feeding. Efforts to improve lean tissue after
the initial effect of HPN will be important to long-term health improvement
while HPN-dependent.
The effect of HPN on survival was explored in the third
study of patients with radiation enteritis as the reason for HPN-dependence. This study demonstrated that HPN did not have a detrimental effect on
survival and that the potential for catheter sepsis in this group was well
within expected ranges for other therapies and other conditions. While one
patient’s death was related to catheter sepsis, the primary reason for death
was the underlying cancer.
Improving oral intake and reducing dependence on HPN is
a reasonable goal for short-term HPN candidates. In the case of HPN
dependence because of short bowel syndrome (SBS), it is more difficult to
realize a reduction in HPN dependence. Strategies such as glutamine
enhancement, oral fiber intake, and growth hormone inducement of intestinal
absorptive capacity have been explored in an effort to reduce dependency. Presumably, the eventual HPN independence
could improve quality of life scores affected by HPN, eliminate catheter,
metabolic, and other potential complications of long-term and life-long HPN,
and potentially reduce related costs.
A team approach is essential to the management of the
transition to homecare for HPEN-dependent patients. Reductions in
duplications of efforts between institutional and homecare personnel in
concert with the prescribing physician can help to maintain the cost
effectiveness of HPN. The fourth article reviewed in this series outlines a
communication strategy for team members to maintain quality care while
controlling costs.
Implications for Social Workers