Guideline for the Selection of Adult Oncology Patients Requiring Home Parenteral Nutrition

GUIDELINE FOR THE SELECTION OF ADULT ONCOLOGY PATIENTS REQUIRING HOME PARENTERAL NUTRITION IN PALLIATION

Version 1

Name of responsible (ratifying) committee Surgery Governance & SIRG

Date ratified 19 October 2017 IF Specialist Dietitian Document Manager (job title) Nutrition Team Consultant Gastroenterologist Date issued 12 December 2017

Review date 11 December 2019

Electronic location Clinical Guidelines Policy for the provision & management of parenteral nutrition in adults in hospital. Nutrition Policy. Refeeding Guidelines (Drug and Therapy Guideline). Related Procedural Documents Pharmacy Homepage>What to do when pharmacy is closed>. Central Venous Catheters: Care and management. Nutrition Policy Asepsis Policy. Nutrition, Parenteral, Palliative, Intravenous, HPN, TPN, Central line, PICC line, Dietitian, Nutrition Nurse, Nutrition Team, Nutrition Support Team, IV therapy Key Words (to aid with searching) Nurse, Pharmacist, Nutrition Ward Round, Food, Patient Diet, Dietary intake, Feeding, Parenteral feeding, Nutrition policy, Nutrition planning, Dietetics, Intravenous therapy, Discharge planning, Hospice.

Version Tracking Version Date Ratified Brief Summary of Changes Author 1 19/10/2017 New Guideline S Gavin/ T Trebble

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 1 of 19 Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 2 of 19 CONTENTS

QUICK REFERENCE GUIDE...... 3 1. INTRODUCTION...... 4 2. PURPOSE...... 4 3. SCOPE...... 4 4. DEFINITIONS...... 4 5. DUTIES AND RESPONSIBILITIES...... 5 6. TRAINING REQUIREMENTS...... 9 7. REFERENCES AND ASSOCIATED DOCUMENTATION...... 9 8. EQUALITY IMPACT STATEMENT...... 9 9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS...... 10 EQUALITY IMPACT SCREENING TOOL...... 11 Appendix 1: BOZZETTI ET AL 2015 NOMOGRAM TO PREDICT SURVIVAL...... 13 Appendix2: GLASGOW PROGNOSTIC SCORE...... 14 Appendix 3: KARNOFSKY PERFORMANCE STATUS...... 15 Appendix 4: HOME PARENTERAL NUTRITION (PN) AGREEMENT...... 16

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 3 of 19 QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Palliative patients with intestinal failure as a result of incurable cancer should undergo formal assessment by Nutrition Support Team (NST) and the Palliative care team for appropriate nutrition support.

2. Selection should include assessment of performance status (e.g. Karnofsky score), clinical outlook (e.g. GPS score), primary diagnosis (e.g. tumour site and prognosis of cancer), and assessment of social support and home environment completed by the lead clinical oncology team.

3. A time-limited trial of parenteral nutrition (PN) as an inpatient should be used to ensure patient finds benefit from nutritional/hydration intervention, and wishes to proceed with TPN in the outpatient setting (e.g. Home or hospice).

4. Documented discussion by MDT to include Oncologist, Nutrition Team Consultant, Palliative Care team, patient and relatives/carers, Dietitian, Nutrition Nurse – with the aim of ensuring clear cost-benefit discussion/consideration of alternatives included in decision to proceed with HPN.

5. Contract to be signed by patient and team at the outset of plan for HPN to explain the process, monitoring and logistics of home parenteral nutrition.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 4 of 19 1. INTRODUCTION

Home parenteral nutrition (HPN) in palliative patients should be considered when enteral/oral nutrition is contra-indicated and does not provide or is not expected to provide adequate nutrition to meet the patient’s expected requirements as a result of intestinal failure caused by incurable cancer. Patient selection must be considered carefully and should involve an MDT discussion with the patient, oncologist, nutrition support team (NST) and palliative care team. Assessment for HPN in palliative patients should include; performance status measurement for example using the Karnofsky Performance Appendix 3 or ECOG score, progression of disease, clinical outlook using the Glasgow Prognostic Score (GPS) Appendix 2 and assessment of home environment. The patient should not be due for further oncology treatment. A nomogram has been validated by Bozzetti et al 2015 and can be used to assist the decision making process Appendix 1.

Parenteral nutrition is a high cost, invasive treatment and associated with significant clinical risk. When considering HPN for palliative patients the benefits must outweigh the burden of HPN.

2. PURPOSE

This Clinical Policy is designed for Healthcare Professionals in Portsmouth Hospitals NHS Trust to support the appropriate selection of adult palliative patients who may receive HPN.

3. SCOPE

This Policy encompasses nutrition provided via an intravenous catheter in palliative patients at home or other health care setting e.g. hospice. It is relevant to all healthcare professionals involved in the:  Selection and nutritional assessment of patients,  Placement of suitable feeding catheter,

To whom the document applies.

This document applies to palliative patients with intestinal failure with an oncology cause requiring HPN.

 This document excludes all patients in hospital who are not due for discharge home with HPN.  This document excludes Paediatric patients.  This document excludes patients who do not have a diagnosis of incurable cancer.  This document excludes patients who are due to have oncology treatment.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS

Parenteral nutrition (PN) PN provides patients’ nutrition by intravenous administration with an artificially prepared solution. PN does not utilise the gastro-intestinal tract and therefore removes an important physiological and immunological barrier. This may therefore expose the patient to an increased Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 5 of 19 risk of metabolic and septic complications. PN can provide the full range of macronutrients i.e. protein, fat, carbohydrate and micronutrients i.e. vitamins, minerals and trace elements, and fluid that the patient requires or it can provide supplementary nutrition in addition to enteral and/or oral nutrition.

Central line Centrally-inserted catheter denotes a catheter (not cannula), placed in the superior vena cava via:  The basilic or cephalic vein (Peripherally-Inserted Central Catheter or ‘P.I.C.C. line’). A single or double lumen PICC line can be placed depending on whether intravenous access is required for parenteral nutrition in addition to other intravenous access for additional fluids, medications, and blood-taking.  The right or left internal jugular vein, or the subclavian vein (central venous catheter or CVC line). These lines are likely to be tunnelled subcutaneously to minimise the risks of sepsis in long-term use.  Subcutaneous port used for long-term intravenous administration.

Nutrition Support Team (NST) The NST is a multi-disciplinary team of health professionals comprising: Lead Consultant – Consultant Gastroenterologist and Physician – Dr Tim Trebble Dietitian(s) from Department of Nutrition and Dietetics PN Pharmacist and/or ward Pharmacist Clinical Biochemist Clinical Nutrition Nurse Specialist(s) IV Therapy Nurse Individual members of the NST undertake the initial and day-to-day assessment and management of patients receiving PN. The NST will undertake ward rounds to review patients referred for or receiving HPN.

Multidisciplinary Team (MDT) NST members Patient, family and carers Clinical lead oncologist Clinical lead palliative consultant Homecare delivery team

Clinical Lead Oncology Team The clinical lead oncology team should include the Consultant Oncologist who has been managing the patient.

Clinical Lead Palliative services The clinical lead palliative services should include the Hospital Palliative Care Consultant and team as well as the Community Palliative Care Consultant and team.

5. DUTIES AND RESPONSIBILITIES

The Clinical Lead Oncologist The Consultant or Registrar should refer to the dietitian for inadequate dietary intake, taking into account all relevant clinical and nutritional factors in the decision. They should consult with individual disciplines involved within the Nutrition Support team who can advise on aspects of nutritional support as required. They should make the referral initially to the Dietitian for that ward/clinical area who will assess the patient’s nutritional status and requirements and set the process in motion or refer onto an experienced dietitian who is part of the nutrition support team.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 6 of 19 The clinical lead oncology team should determine whether the patient is for further oncology treatment. The palliative care team should be invited to be involved if the patient is not for further oncology treatment.

Clinician on the Nutrition Support Team This is a Consultant/Registrar with an interest and expertise in Nutrition, especially artificial feeding and clinical nutrition, to lead the Nutrition Ward Round and provide clinical input into the decisions relating to nutrition/ access.

Specialist Dietitian The Specialist Dietitian is responsible for assessing the patient’s nutritional status and estimating appropriate nutrition requirements within 24 hours of referral (Monday to Friday). They will advise on the appropriateness of PN and any future HPN as well as any alternative enteral routes, consulting medical staff within the primary referring team and the Nutrition Support Team as appropriate. The dietitian will:  Select an appropriate feeding regimen and will liaise with the designated PN pharmacist regarding the regimen required.  Liaise with the IV Therapy Nurse to request a PICC line if no dedicated central venous catheter is available for PN administration. The Dietitian or IV therapy nurse will recommend a multi-lumen line if other IV access is required in addition to PN or the PN regimen is not going to provide adequate fluid and additional IV fluids will be needed.  Consult with the Nutrition Support Team (NST) as appropriate and review the patient, to ensure optimal nutrition (subject to the patient’s clinical status) is maintained throughout according to the patient’s clinical status.  Will formulate HPN regimen with homecare pharmacists before discharge with HPN.  Will liaise with the nutrition nurses regarding discharge planning on HPN.  The ongoing management of these patients is beyond the scope of this document.

Pharmacist The designated PN pharmacist will prescribe PN as requested by the dietitian per the Trust PN policy. Hospital pharmacy homecare team to send off signed HPN prescription as per Home Parenteral Nutrition Pathway.

IV Therapy Nurse The IV Therapy Nurse will receive requests from the Dietitian or members of the Nutrition Support Team if a Peripherally Inserted Central Catheter is required for the provision of HPN. They will assess the patient for suitability and insert a PICC line if possible/feasible at the earliest opportunity. They will review the catheter site for evidence of infection, occlusion or failure, advise on line management and provide support and training for the ward nursing and medical staff. They IV team will be available to place new PICC lines or repair damaged lines as required for HPN patients when discharged.

Clinical Nutrition Nurse Specialist The Clinical Nutrition Nurse Specialists are responsible for the discharge planning process and setting up of HPN via the selected Homecare Company. The Nutrition Nurse will:  Assess the patient for ability to safely manage HPN at home.  Identify who will administer HPN: patient, carer, Homecare nurses  Select HPN Homecare Company and register the patient for supplies and nursing support.  Inform clinical area of planned installation and discharge date.  Provide pharmacy Homecare team with patient registration form, ancillary form and final prescription  Assess suitability of IV access for HPN: PICC vs Hickman need for extension set if patient has PICC and managing HPN independently.  Educate patient/carer on principles of asepsis and risks associated with HPN.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 7 of 19  Provide patient information folder detailing contact numbers, follow up appointments, HPN management plan.  Check line dressing/ ends of line just prior to discharge.

Clinical Biochemist The Clinical Biochemist is part of the Blood Sciences Department and a member of the Nutrition Support Team and available on request to advise on blood sciences as needed.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 8 of 19 Review by Clinical Lead Lead Oncology team to determine; Oncology team and  Patient is not for further oncology treatment referral to the ward  Patients performance score e.g. KPS Dietitian  Patients clinical status e.g. GPS

Patient is reviewed by NST and Palliative care. Nutritional options discussed with patient and family

Decision to withdraw HPN made with Palliative care, Decision to proceed with PN NST and patient Contract signed by patient and team

No Yes

Continued monitoring by NST and Palliative care Palliative team to advise on Trial PN and monitor benefit to including checkpoint review further treatment options patient of prognosis and benefit of PN

Dietitian to meet nutritional requirements via PN and condense 4-6 Weeks duration to promote day leave

Dietitian to arrange discharge Nutrition Nurses to arrange Homecare and monitoring on the Company to provide HPN and nursing care. Intestinal Failure Virtual Ward Date for possible discharge home Programme

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 9 of 19 6. TRAINING REQUIREMENTS

The skills required for individual members of the Nutrition Support Team are generic skills provided within their routine roles. Each discipline will provide training and support and check competencies for new members of their profession on the NST. Individual members will provide advice within their scope of practice to ward and medical staff on best practice as described in this Policy.

Registered Nurses should have successfully completed the IV Study Day before working autonomously with IV fluids.

7. REFERENCES AND ASSOCIATED DOCUMENTATION

 ESPEN Guidelines on parenteral nutrition: home parenteral nutrition in adult patients, 2009  ESPEN Guidelines on parenteral nutrition: non-surgical oncology, 2009  Development and validation of a nomogram to predict survival in incurable cachetic cancer patients on home parenteral nutrition. Bozzetti et al, Annals of Oncology, 2015  Policy for the provision and management of parenteral nutrition in adults in hospital, Portsmouth Hospitals NHS Trust, 2014

The following referencing format must be used:

An Organisation-Wide Policy for the Development and Management of Procedural Documents: NHSLA, May 2007. www.nhsla.com/Publications/

8. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Quality of care Working together Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 10 of 19 Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 11 of 19 9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum Lead Tool Frequency of Report Reporting arrangements Lead(s) for acting on requirement to be of Compliance Recommendations monitored Audit of patient Dr Tim Electronic Annual Policy audit report to: Dr Tim Trebble selection Trebble database  Nutrition Steering group Sarah Gavin

This document will be monitored to ensure it is effective and to assurance compliance.

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 12 of 19

EQUALITY IMPACT SCREENING TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Home Parenteral Nutrition in Palliation (Adults) Guidelines

Date of Assessment 17/10/17 Responsible Dietitians Department Name of person Sarah Gavin Job Title Specialist Dietitian completing assessment Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Comments  Age N  Disability N Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia  Ethnic Origin (including gypsies and travellers) N  Gender reassignment N  Pregnancy or Maternity N  Race N  Sex N  Religion and Belief Y See full impact assessment  Sexual Orientation N If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below www.legislation.gov.uk/ukpga/2010/15/contents

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 13 of 19 Stage 2 – Full Impact Assessment What is the impact Level of Mitigating Actions Responsible Impact (what needs to be done to minimise / Officer remove the impact) PN lipid contains egg therefore Low Vegan patients may choose to Nutrition support it may not be suitable for strict have lipid free PN nags team. Consultant vegans or Registrar from primary clinical team Vitamin and excipient are not The additions can be added or vegetarian or vegan when Low not, however there are clinical added to the bag of parenteral issues regarding the provision nutrition. There are no suitable of PN without vitamin and alternatives manufactured. minerals which could Vegetarians and vegans are potentially be harmful and the disadvantaged when prescribed decision would need to be parenteral nutrition as there are made in consultation with the no alternatives available from patient and the patient’s any company producing PN medical team in consultation with the Nutrition Support Team.

Monitoring of Actions The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 14 of 19 Appendix 1: BOZZETTI ET AL 2015 NOMOGRAM TO PREDICT SURVIVAL

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 15 of 19 Appendix2: GLASGOW PROGNOSTIC SCORE

Glasgow Prognostic Score

CRP Albumin

Score of 0 <10 mg/L >35 g/L

Score of 1 >10 mg/L or <35 g/L or

Score of 2 >10 mg/L <35 g/L

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 16 of 19 Appendix 3: KARNOFSKY PERFORMANCE STATUS

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 17 of 19 Appendix 4: HOME PARENTERAL NUTRITION (PN) AGREEMENT Home Parenteral Nutrition (PN) Agreement

What we expect from you……  To agree to have a pharmacy grade fridge and equipment for PN installed in your home

 To agree to receive fortnightly or monthly deliveries of PN and equipment into your home

 To agree to have Home care nurses coming in your home to connect and disconnect PN initially, and to train you or your family member to do this over a period of time, if appropriate

 To look after and manage your I.V line as instructed

 To attend Nutrition Nurse clinic weekly for bloods and line dressing

 To contact the Nutrition Nurse team if you have any line related problems and attend QAH if necessary

 To have bloods taken and urine samples as required

 This may be required up to twice per week at most

 Samples must be transported to your GP surgery or pathology at QA

 To use the parenteral nutrition as directed

 To use additional intravenous fluids as directed by us

 To inform the team if any bags of PN are missed

 To record your oral intakes and outputs from drains, stomas or urine as required

 To discuss with the team if you no longer wish to have PN e.g.

 If it becomes too much of a burden

 You no longer find any benefit from PN

 To attend clinic appointments with the team as required Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 18 of 19  To attend the hospital for infusions as an outpatient as required

What you can expect from us……  To set up home care nursing for connecting and disconnecting and completing training as required

 To provide the homecare team with instruction for the PN prescription and equipment required, amending these as needed

 To minimise the number of visits required to the hospital for nutrition related issues

 To call you and discuss the results of your blood tests

 To discuss your care in the nutrition team meetings each week

 To provide direct, same day, access to the Nutrition Nurse led clinic for any I.V line related problems

 To communicate any plans or changes with your lead Consultant

 To inform your GP in writing of any prescriptions they need to continue

 To be available to answer any nutrition related questions by phone Monday- Friday 08:30-16:30

Copy for patient  Copy for notes  Patient signature: Nutrition Team Member signature:

Home Parenteral Nutrition in Palliation (Adults) Guidelines Version: 1 Issue Date: 12 December 2017 Review Date: 11 December 2019 (unless requirements change) Page 19 of 19