Guidelines for parenteral and enteral nutrition in geriatric patients in China

Abstract Based on the expert consensus on parenteral and enteral nutrition support for geriatric patients in China in 2013, domestic multidisciplinary experts were gathered to summarize the new evidence in the field of elderly nutritional support at home and abroad. The 2013 consensus was comprehensively updated and upgraded to a guideline by referring to the World Health Organization (WHO) guidelines for the Grading of Recommendations Assessment, Development, and Evaluation system for grading evidence. These guidelines were divided into two parts: general conditions and common diseases. After discussion by all members of the academic group and consultation with relevant experts, 60 recommendations were ultimately established as standardized nutritional support in the field of geriatrics in China.


| DE TERMINING ENERGY AND PROTEIN
A variety of methods can be used to measure the energy requirements of elderly hospitalized patients. Resting energy expenditure (REE) is currently considered the gold standard for measuring human energy expenditure. In view of the significant individual differences in REE among the elderly, the energy expenditure should be measured in real time by IC, rather than by simply using formulas for estimation or prediction. In a study on energy expenditure estimation in elderly patients, it was found that the REE of hospitalized patients varied as a function of body mass index (BMI): the average REE of patients with BMI below 21 kg/ m 2 was 21.4 kcal/kg/d, while the average REE of patients with BMI higher than 21 kg/m 2 was 18.4 kcal/kg/d. 6 Several guidelines at home and abroad have suggested that 20-30 kcal/kg/d could be taken as the target amount for most elderly patients. Achieving the target energy intake can improve the long-term prognosis of patients and reduce mortality. 1,7 For elderly patients, current dietary recommendations might underestimate their protein requirements. It is generally believed that elderly patients with normal renal function have a target protein intake of 1.2-1.5 g/kg/d, and more significant clinical benefits could be obtained by increasing simple exercise activities. To seek the optimal protein intake level for the elderly, the multinational PROT-AGE study, led by the European Union, has carried out extensive evidence-based analysis and discussion. The study recommended at least 1.0-1.2 g/kg of protein per day if safe and tolerable; for the elderly who perform regular exercise or activity, more protein is recommended (≥1.2 g/kg); the elderly with acute or chronic diseases need 1.2-1.5 g/kg/d of protein intake. Patients with severe kidney disease but who are not on dialysis (glomerular filtration rate < 30 mL/min/1.73 m 2 ) need to limit protein intake. 8 In China, it is also recommended that the daily protein intake of elderly patients should be 1.0-1.5 g/kg, and a certain amount of physical exercise and activity is recommended. As the absorption rate of whey protein is about twice that of casein, enteral nutrition (EN) formulations containing whey protein are more likely to meet the protein requirements of the elderly than EN formulations containing only casein. 1 Question: How do we optimize the proportion of energy provided by fat and pharmacological supplements? Current dietary guidelines for elderly Chinese residents state that the total fat intake of the elderly should account for 20%-30% of their total energy consumption. In general, elderly patients should be given EN preparations with optimized fatty acid formulations, such as those containing higher chain fatty acids and omega-3 fatty acids, which can help improve lipid metabolism. For some patients with partial intestinal malabsorption, severe exocrine pancreatic insufficiency, or severe hyperlipidemia, low-fat EN preparations (energy from fat < 5%) can be considered. For critical patients and cancer patients, appropriately increasing the proportion of energy provided by fat is conducive to improving nutritional status. 1 Elderly patients receiving PN treatment can receive increased fat for energy and reduced glucose, as appropriate, which can improve clinical outcomes. Breitkreutz's study 9 found that increasing the proportion of energy provided by fat in PN to 40%-50% can meet the energy expenditure of patients without increasing risks, such as disturbances of blood glucose, respiratory failure, and changes in liver and kidney function. European parenteral nutrition guidelines for the elderly suggest that patients with hyperglycemia and cardiac and renal impairment might need to receive a higher fat content PN formula of up to 50% of total energy. 7 For elderly patients with critical diseases and after major surgery, adding glutamine to the EN or PN formula can improve nutritional metabolism, maintain intestinal barrier function and immune function, and reduce serious complications, such as ectopic intestinal flora and infection. [10][11][12] However, in the REDOx study, 13 for patients with shock and multiple organ failure or hemodynamic instability requiring vasopressor support, excessively high doses of glutamine (>0.5 g/kg/d) can increase mortality. Given kidney function in the elderly declines with age, the tolerance for glutamine supplementation must be considered. A study has shown that oral supplementation with glutamine in elderly patients can lead to increased serum urea nitrogen and creatinine and a lower estimated glomerular filtration rate in elderly patients. Although it has no significant clinical significance, the renal function of patients should be monitored and the dose be limited to below 0.5 g/ kg/d. 14 Many studies and guidelines at home and abroad have suggested that reducing some omega-6 fat emulsions and increasing pharmacological doses of omega-3 fatty acids (such as fish oil fat emulsions) in PN formulas can decrease the level of inflammatory factors, reduce the incidence of infection and systemic inflammatory response syndrome, and shorten the length of hospital stay. 7,15 A systematic review on the use of fish oil for 6-52 weeks and an oral dose of 0.03-1.86 g/d concluded that oral fish oil supplementation for the elderly has a lower risk of adverse reactions and serious adverse reactions and is clinically safe within the dose range of this study. 16  In multiple guidelines at home and abroad, the NRS2002 is recommended as a useful screening tool for nutritional risk among inpatients, including the elderly. The MNA-SF is based on six simple questions regarding medical history, weight, diet assessment, and a simple physical examination, which together determine whether a patient has malnutrition or is at risk of malnutrition. The assessment should be carried out as early as possible to achieve better clinical outcomes. 1,7 Zhu et al used the NRS2002 and MNA-SF methods to conduct a nutritional screening survey for inpatients in 34 large hospitals in 18 major cities in China. 17 It was found that 51.41% of elderly inpatients had nutritional risks, and that complications and lengths of stay of elderly patients with nutritional risks were higher than those not at nutritional risk. 17 Skipper et al published an evidence-based analysis of the sensitivity and specificity of the MNA-SF, NRS2002, subjective global assessment (SGA), and other tools and found that the MNA-SF was more conducive to the assessment of elderly patients than the other tools. 18 A comprehensive nutritional assessment explains and expands on information obtained from nutrition screening. Nutrition professionals analyze and evaluate clinical information, and comprehensively judge medical and nutritional intake history, digestion, and absorption capacity, data from the physical examina-  (Evidence level B, strong recommendation, 97%) Recommendation 13: Dietary fiber added to formula can reduce the incidence of diarrhea and constipation in patients with tube-feeding EN, and dietary fiber intake ≥25 g/d can reduce constipation and improve clinical outcomes in patients with tube-feeding.

| ENTER AL N UTRITI ON TRE ATMENT
(Evidence level A, strong recommendation, 88%) Standard total protein formulas are suitable for most elderly patients, and the amino acid or short peptide EN formulas are best for patients with gastrointestinal function deficiency (such as severe acute pancreatitis). Formulas with high energy density can improve the nutritional status of elderly patients. Whey protein can promote protein synthesis and weaken protein synthesis resistance in older people, and it provides more essential amino acids than casein. Older patients are likely to suffer from lactose intolerance due to lactase deficiency, and diarrhea is common. Formulas without lactose can be used for these patients. Reducing the use of formulas rich in saturated fatty acids and increasing the amount of medium-chain fatty acids and monounsaturated fatty acids is recommended for the elderly, as all of these supply energy rapidly and reduce the metabolic burden to the liver. Such formulas can also reduce the risk of cardiovascular disease in long-term management. 24 Dietary fiber can improve the intestinal function of elderly patients who receive tube-feeding EN for extended periods of time, and fiber can also reduce the incidence of diarrhea and consti- ONSs should be the preferred nutritional intervention for elderly patients with malnutrition or at risk of malnutrition, and when the regular diet cannot meet the requirements of the total body amounts (<60% of the target amounts). ONSs have the advantages of simplicity, convenience, and low price, and can satisfy the psychological desire of elderly patients to consume nutrition orally. In most cases, total nutrition formulas are recommended when using ONSs, including EN formulas or food for special medical purposes. ONSs can be used either as a substitute for some foods in the diet or as a supplement to increase intake and provide 400-600 kcal daily, and oral administration between meals is considered the standard nutritional intervention therapy for ONS. 26 Huynh et al 27 gave ONSs (432 kcal/d) for 12 weeks to 106 elderly patients who were at nutritional risk. Compared with a control group, they gained weight and improved their BMI (P = 0.0009).
In two Chinese studies, 28,29 ONSs (500 kcal/d, oral administration between meals) were given to patients receiving neoadjuvant In a systematic review of 36 RCTs, a high-protein ONS formula had clinical, nutritional, and functional benefits, including reduced complications and readmission rates, improved grip strength, and increased intake of total energy and protein. 32 A higher-protein ONS formula also significantly improved muscle strength and quality of life in elderly patients with sarcopenia. 33 In an RCT study including 652 elderly hospitalized patients with SGA scores of B and C, the 90-day mortality rates in the intervention group with high HMB supplementation were significantly lower than those of the control group, and the intervention group achieved better nutritional status (according to the SGA classification) on the 90th day, as well as significant weight gain on the 30th day. 34 Recent studies have found that elderly patients undergoing ONS obtained benefits including a significant improvement in their quality of life and a reduction in complications and costs. 35 A long-term study of compliance with ONS in cancer patients by Bolton et al 36 found that 54% of patients stopped due to disliking the taste. Related factors influencing the overall evaluation of ONSs were as follows: taste, aroma, appearance, taste after drinking, flavor intensity, sweetness, and thickness. Although more than 10 flavors of ONS formulas, such as vegetables, fruits, chocolates, strawberries, and coffee, have been developed abroad, there is still a big difference in taste compared to natural diets.
Question: How do we choose the route of enteral tube-feeding?
Recommendation 19: Nasogastric tubes are suitable for elderly patients who receive short-term tube-feeding (2-3 weeks). Elevating the head to 30-45 degrees can prevent aspiration pneumonia.
(Evidence level C, strong recommendation, 99%) Recommendation 20: For elderly patients undergoing major abdominal surgery who are expected to need long-term postoperative tube-feeding, placing a jejunostomy, or nasogastric tube during the operation is recommended. When a proximal gastrointestinal anastomosis is performed, EN can be performed through a jejunal nutrition tube placed at the distal end of the anastomosis. (Evidence level C, weak recommendation, 92%) Recommendation 21: For elderly patients who need long-term nutritional support, percutaneous endoscopic gastrostomy (PEG) is recommended over a nasogastric tube. PEG is recommended for tube-feeding EN that is expected to be used for more than 4 weeks. Tube-feeding can meet energy and nutrient requirements and improve nutritional status for elderly patients. 1,7 The selection principles for the various routes include the following: the choice should suit EN; the insertion procedure should be easy and convenient with minimal injury to patients; and the choice should be comfortable and conducive to long-term tube-feeding if that is required. Nasogastric tubes are the most commonly used EN route. Nasogastric tubes are suitable for elderly patients who receive short-term tube-feeding (2-3 weeks). Elevating the head to 30-45 degrees can prevent aspiration pneumonia. 1 For patients receiving proximal gastrointestinal anastomosis, the placement of a jejunal feeding tube at the distal end of the anastomosis can reduce the impact on the gastrointestinal anastomosis and is conducive to implementing early EN. 1 Studies have confirmed that PEG is superior to nasogastric tubes because it provides more energy, is better at maintaining or improving nutritional status, and is not involved in tube displacements or reinsertions. A few studies have found improvements in the quality of life of patients with PEG and no difference in mortality, but the incidence of aspiration pneumonia in patients undergoing PEG is lower than that with nasogastric tubes. Therefore, if EN is anticipated for longer than 4 weeks, and there are no contraindications and the consent of the patient or family members is obtained, PEG is recom- China found that if only EN was given, only 31.8% of surgical patients achieved the target feeding amounts. 37 Heyland et al 38 surveyed 3390 ICU patients in 201 centers and found that 74.0% of patients failed to reach 80% of the target energy intake, and protein supply was only 57.6% of the target amount. The RCT study conducted by Heidegger et al 39 showed that for critically ill patients whose EN did reach the target feeding amount of 60%, SPN was given on the 4th-8th days after entering the ICU, and nearly 100% of the energy supply reached the targets. Compared with continuous EN, the 28-day nosocomial infection rate of the SPN group was significantly reduced (P = 0.0338). In recent years, additional studies have reached similar conclusions, which could be attributed to the fact that when the energy supply of EN is less than 60% of the target amount, it directly affects the nutritional status and organ function of elderly patients and results in increased complications. 40 In this case, the advantages of SPN in improving energy and protein supply are highlighted. Protein anabolism is promoted, thus maintaining the functions of tissues, cells, and organs, and promoting the repair of autophagy in severe conditions. Question: When do elderly patients start using PN? The conflicting results are related to the type of disease, disease severity, and preoperative nutritional status. Jie et al 43 found that patients at low nutritional risk (NRS2002 score 3-4 points) and who were given nutritional support did not receive a clear benefit, while those at high nutritional risk (NRS2002 score ≥ 5) had significantly reduced infectious and non-infectious complications. The study conducted by Heyland et al 44 showed that the nutritional support effect for critical patients with NUTRIC scores ≥ 6 was significantly better than that for patients with a NUTRIC score ≥ 5. Therefore, the   56 Nutritional support should be staged, that is, 25% of the total amount given at the beginning and the balance achieved 3-5 days later. Changes in water and electrolytes should be closely monitored. High-risk factors for aspiration pneumonia due to gastroesophageal reflux include disturbances of consciousness, inadequate posture, sedation, critical illness, vomiting, and gastric retention.

| MONITORING AND MANAG EMENT OF PARENTER AL AND ENTER AL N UTRITI ON
Monitoring of gastric residual volume is also related to the prevention of aspiration pneumonia. Some studies have found that when the gastric residual volume is greater than 250 mL and the patient has more than one risk factor, or when the residual volume is more than 200 mL and the patient has more than two risk factors, adjusting the EN method should be considered. These adjustments could include a change in intubation position, a decrease in infusion speed, a change to PEG/percutaneous endoscopic jejunostomy, or an end to EN.

| Cardiovascular disease in the elderly
Question: How do we provide nutritional support for elderly patients with heart failure? A meta-analysis of RCT studies of nutritional counseling interventions in patients with heart failure showed that nutritional counseling is effective in improving the prognosis of elderly patients with heart failure, despite differences in nutrient composition and food quality. 60 There is a lack of high-quality clinical studies on PN or EN support in patients with cardiac insufficiency and malnutrition. A study on 105 elderly patients with chronic heart failure found that the use of EN in conventional treatment not only improved nutritional status and heart function, but also improved immune function, which in turn reduced inflammatory factor levels. The longer the treatment time, the greater the improvement in cardiac function and inflammatory factors. 61 Use of PN is safe and well tolerated during the perioperative period in patients with heart failure who are treated with ventricular assistance devices. 62  (Evidence level C, strong recommendation, 94%) A study found that the incidence of malnutrition in outpatients with COPD was 25%, compared with over 50% in hospitalized patients and over 60% in patients with acute respiratory failure, of which 43% were patients not on mechanical ventilation, 74%

| Chronic obstructive pulmonary disease
were patients on mechanical ventilation, and 88% of patients on mechanical ventilation for more than 6 days had malnutrition. 63 COPD patients generally suffer from insufficient nutritional intake, which affects the development and outcome of COPD. A meta-analysis by Ferreira et al 64 found that nutritional interventions for COPD patients with low bodyweight significantly improved the patients' weight, upper arm circumference, and maximum inspiratory expiratory pressure. Given the higher respiratory quotient of carbohydrates, high carbohydrate intake can increase oxygen consumption in patients with COPD, increase patient symptoms, and reduce compliance with nutritional support. A cohort study found that EN with an increased fat-to-energy ratio significantly improved nutritional status and respiratory function. 65 At least 1.5 g/kg/d of protein is recommended to increase muscle mass and promote protein synthesis. A study has found that the prevalence of COPD was lower and lung function was better in a population with high dietary fiber intake. 66 The use of omega-3 fatty acids is beneficial for respiratory function and prognoses for the elderly with COPD in the acute stage.
Patients with COPD often suffer from poor appetite due to weak overall status, and patients in the acute stage might have more significant dysphagia due to difficulties with breathing, chewing, and swallowing. One RCT included 128 patients with COPD patients who were underweight (<95% of their ideal weight) and showed that megestrol acetate (800 mg orally once daily) was associated with weight gain and appetite improvement. 67 There is no evidence of severely impaired bowel function in patients with acute COPD, and EN should be the first choice for these patients.
If the EN supply does not reach the target amounts (60%) after 2 days, SPN will be required. 7 An RCT compared the effect of energy supply by indirect calorimetry and by the use of 25 kcal/kg/d on the length of hospital stay and mortality. It was found that the strict energy supply determined by indirect calorimetry can reduce hospitalization time and hospital mortality by over 50%. 68 Therefore, it may be more beneficial to measure energy consumption by direct calorimetry and strict planning of energy supply. For most critically ill patients, a safe start for calorie supplementation is 8-10 kcal/kg/d. 69 For most stable patients, the target amount of 25-30 kcal/kg/d should be reached after 1 week. PN could help avoid the risks caused by high-fat EN, such as gastric emptying and aspiration. Some 35%-65% of lipids can be used as non-protein energy sources in the PN prescription. The recommended amino acid target is 1.3-1.5 g/kg, and vitamins and micronutrients should be simultaneously supplemented. 7 During the nutrition intervention process, oxygen consumption and carbon dioxide production will increase, which can aggravate the symptoms of dyspnea and increase weaning difficulties in patients with COPD, thus, avoiding overfeeding is important. An RCT on patients with acute respiratory distress syndrome compared a constant infusion of lipids over 6 hours or 24 hours, and the slower infusion rate (24 hours) with a lower shunt fraction was associated with improved arterial oxygen partial pressure (PaO 2 ) and fractional inspired oxygen (FiO 2 ). Therefore, it was recommended that the fat infusion rate should not exceed 0.05-1.0 kcal/kg/h. 70  Nutritional therapy can improve the nutritional status and general condition of patients with AD 1,7 and ONSs are beneficial to the nutritional management of these patients as they increase energy and nutrient intake. A study found that patients with AD with a BMI of 25 kg/m 2 were given ONSs for 3 weeks to 1 year, and the calories were 125-680 kcal/d. The results suggested that ONSs were well tolerated and helped increase weight and BMI. 71 Compared to diet counseling and guidance, ONSs are more suitable for elderly patients with early and moderate dementia and can ensure adequate energy and nutrient supply, promote weight gain, and prevent the occurrence and development of malnutrition. 72 Tube-feeding in patients with AD is currently controversial.

| Alzheimer's disease
For patients with AD at various stages of the disease, if there are clinical complications (such as pneumonia, stroke, or after surgery), tube-feeding EN can be applied (assuming it is not contrary to the patient's wishes) to reduce the nutritional risk of reduced energy intake. 73 Short-term tube-feeding is recommended in patients with AD with fluctuating or emergency conditions, such as pneumonia or airway edema. Patients with AD who have indications for nutritional treatment can use PN if tube-feeding is not tolerated or EN is contraindicated. The use of PN or EN in the end-stages of AD is not recommended. 74

| Diabetes mellitus
Question: How do we perform nutritional support treatment for hospitalized elderly patients with diabetes mellitus? Although patients with severe malnutrition can benefit from preoperative nutritional support, if they need to undergo major surgery, it is difficult to endure long-term nutritional deficiency. In addition, these patients need nutritional support after surgery. For patients with severe malnutrition who have not received nutritional support before surgery, postoperative nutritional support can effectively reduce the incidence of complications and mortality and shorten the length of stay. 82 Most patients who have surgery can eat independently within 7 days after surgery (>60% of target energy requirements), and their clinical outcomes are not significantly different from those who receive nutritional support. On the other hand, mortality and length of stay are significantly increased in patients who cannot eat for more than 10 days without nutritional support. Adequate postoperative (>60% energy and protein target requirements) and early postoperative (within 48 hours) nutritional support can significantly reduce postoperative hospital stay and costs. 83 A retrospective analysis of critical surgical patients showed that the risk of death was significantly higher in patients who received less than 60% of their target energy requirements than in patients who received more than 60%. 84 A systematic review showed that an immunomodulatory formula containing omega-3 fatty acids, arginine, and RNA for perioperative nutritional supplementation could reduce the incidence of postoperative complications and shorten the length of stay. 85 Question: How do we provide nutritional support for elderly patients during the perioperative period?
Recommendation 51: ONSs are the first choice for perioperative nutritional support in the elderly, followed by tube-feeding EN.
When tube-feeding EN cannot be implemented or EN cannot pro- With an increase in EN tolerance and a decrease in PN requirements, PN can be stopped when the energy and protein provided by EN is greater than 60%. 7 Early EN after surgery not only provides nutritional substrates, but it also reduces the body's high catabolic response and insulin resistance, reduces the release of inflammatory factors, maintains the intestinal mucosal barrier and immune function, and prevents intestinal bacterial translocation. The results of multiple studies show that the incidence of complications, such as anastomotic rupture and aspiration, within 24 hours after surgery is not increased compared with fasting patients, and clinical outcomes improve.

| Dysphagia
Question: How should a nutritional support treatment plan be for- Caiteng's seven-grade dysphagia score method is often employed.
In the entire phase of dysphagia treatment, the clinical nutritionist should collaborate with the rehabilitation therapist on formulating a "compensatory method" and a standardized "training diet" to assist rehabilitation. Studies have shown that increasing food viscosity can prolong the time of food entering the throat and help improve the nutritional status of patients with dysphagia. 86 For short-term EN support, a nasogastric tube can be used. For long-term (≥4 weeks) EN, PEG should be used for tube-feeding. 1

| Pressure ulcers
Question: How do we choose a nutritional support method for elderly patients with pressure ulcers? For elderly patients with pressure ulcers who are well orally fed, the first recommendation is a diet intervention under the guidance of a professional nutritionist. If the intake is still less than 60% of the target amounts, ONSs can be provided. A systematic analysis showed that high-protein ONSs can significantly reduce the incidence of pressure ulcers in hospitalized patients and have a beneficial effect on the healing of pressure ulcers. 87 Studies have confirmed that EN can reduce the incidence of pressure ulcers and reduce the cost of hospitalization for high-risk patients with pressure ulcers, and the use of EN for patients with pressure ulcers can improve the prognosis and reduce total hospitalization costs. 88 RCT studies have confirmed that nutrients rich in arginine, vitamin C, and zinc can promote wound healing in patients with pressure ulcers compared with typical EN preparations. 89

| Frailty
Question: How do we carry out nutritional support treatment for patients with senile frailty?  Adequate protein supply and reasonable protein intake can overcome the resistance to muscle protein synthesis in the elderly, effectively maintain muscle mass and function, help slow the development of sarcopenia, and might improve health and clinical outcomes. Prospective studies have confirmed that high-protein intake can reduce the loss of lean body mass by 40%, and increasing protein intake by 20% will reduce the risk of frailty by about 32% in the elderly. 92 The synthesis of muscle protein varies with the intake of various types of protein, which mainly depends on the content of essential amino acids and branched chain amino acids in the protein, and on the digestion and utilization of food proteins. Leucine plays an important role in stimulating muscle protein synthesis. Ingestion of proteins with a high proportion of leucine, in conjunction with other nutrients, can reverse the decline in muscle mass and function in the elderly. 93 Whey protein is rich in leucine, which can be digested and absorbed quickly. It can promote muscle synthesis more than soy protein or casein after rest or exercise. The proportion of whey protein in the nutritional formula for patients with senile sarcoma should be 60% or more. 94 A meta-analysis suggests that vitamin D supplementation can improve skeletal muscle strength. Vitamin D supplementation has a more pronounced effect on skeletal muscle strength in elderly patients. 95 Supplementation with omega-3 polyunsaturated fatty acids can also increase grip strength and protein synthesis in the elderly. 96 A multicenter RCT study found that ONSs (330 kcal, 20 g protein, 499 IU vitamin D3, 1.5 g HMB, twice per day) for 24 weeks could improve the skeletal muscle strength and muscle mass of malnourished elderly patients with sarcopenia. 33

| End-stage elderly patients
Question: What are the goals and methods of nutritional management for end-stage patients?
Recommendation 60: For end-stage elderly patients, the purpose of intervention is comfort rather than life prolongation, and nutritional assessment and intervention are not recommended. We can support the patient's desire to drink and eat but should not insist. Gentle care should be given for end-patients to relieve pain.
(Evidence level D, weak recommendation, 86%) A lack of appetite or an inability to eat in end-stage elderly patients is a manifestation of the end-of-life process, and there is no evidence that artificial nutrition can prolong life or improve the quality of life in these patients. Active nutritional support does not make these patients better, and it might increase the incidence of some side-effects, such as aspiration, infection, and fluid overload, and it increases medical costs. Moderate eating can make patients comfortable and can be psychologically consoling. 97 For end-stage patients, gentle care is important. We should support patients who want to drink and eat, and respect patients' rights to select whether and what to eat on their own. Active nutritional intervention is not recommended. Soft and easily digestible food can be provided according to the patient's preferences, and the intake of salt, sugar, and fat should not be restricted too much.

CO N FLI C T S O F I NTE R E S T
There are no conflicts of interest to be reported by the authors of this study.