Clinical Resource Guide: Appetite Stimulants

Appetite stimulants are often considered for patients experiencing significant weight loss or anorexia related to their underlying terminal conditions.

 INTRODUCTION TO APPETITE STIMULANTS IN THE HOSPICE SETTING 

Cachexia, a common symptom in advanced cancer, chronic obstructive pulmonary disease (COPD), heart failure, and neurological diseases, is characterized by severe muscle wasting and a decrease in appetite that cannot be reversed by nutritional intake alone. Anorexia-cachexia syndrome affects both physical well-being and psychological health, as patients and their families may struggle with the emotional distress of not eating and persistent weight loss. 

Appetite stimulants may be considered in an attempt to increase food intake and potentially improve the patient’s quality of life. However, it is important to emphasize that weight gain or the restoration of normal eating patterns is rarely achieved at this stage. It is also important to remember the focus in hospice care remains on improving comfort and addressing symptoms rather than reversing disease processes. With this in mind, the role of appetite stimulants must be reviewed for alignment with the goals of hospice, particularly when considering potential side effects and the realistic outcomes of treatment. 

DETERMINING APPROPRIATENESS OF APPETITE STIMULANTS IN HOSPICE 

Determining whether to initiate an appetite stimulant in hospice requires a thorough understanding of the patient’s clinical condition, prognosis, and personal goals. Generally, appetite stimulants may be trialed when there is a clear indication that improved appetite would contribute to the patient’s comfort or overall sense of well-being, and when the risks of the stimulant are minimal compared to the potential benefits. 

For example, some patients experience significant distress from the sensation of not wanting to eat, despite a lack of hunger. Families may also experience distress when a loved one is not eating, as food intake is often associated with nurturing and survival. In these cases, an appetite stimulant might be considered to reduce psychological discomfort, even if it does not prolong life or result in substantial weight gain.

A trial of an appetite stimulant may also be appropriate when the patient has expressed a desire to eat more, especially if anorexia is causing significant weakness, fatigue, or a decrease in the ability to participate in activities that enhance quality of life. However, the decision should be individualized, considering factors such as the patient’s remaining life expectancy, potential side effects of the stimulant, and whether the medication aligns with the overall goal of comfort-focused care. If side effects outweigh benefits, discontinuation should be considered promptly. 

EFFICACY OF APPETITE STIMULANTS IN THE HOSPICE SETTING 

The use of appetite stimulants in hospice has been debated, particularly regarding their effectiveness in improving overall quality of life. Appetite stimulants may provide modest benefits in increasing appetite and promoting food intake, but these effects do not always translate to improved physical strength, weight gain, or survival. 

In many cases, appetite stimulants can help alleviate distress related to the psychological burden of not eating, for both patients and families. A patient who can eat small amounts comfortably may feel more "normal," which can improve emotional well-being. Some patients report feeling more satisfied with meals or less anxious about the physical experience of anorexia when treated with appetite stimulants. Additionally, for families, the sight of a loved one eating—even minimally—may ease emotional suffering. 

However, the potential benefits must be balanced against possible side effects, such as fluid retention, gastrointestinal discomfort, or increased risk of thromboembolism. In the hospice setting, where the primary aim is to enhance comfort, it is critical to ensure that appetite stimulants do not unintentionally cause harm or discomfort. 

Moreover, research has shown that while appetite may improve with certain agents, weight gain is rarely achieved. This is because cachexia involves metabolic changes beyond simple anorexia, including the breakdown of muscle mass and altered metabolism, which appetite stimulants alone cannot reverse. Therefore, the impact on quality of life is most likely to be observed in the psychological and emotional domains rather than physical function or longevity

PHARMACOLOGIC APPETITE STIMULANTS 

The table below is intended to help guide the selection of the most appropriate appetite stimulant based on the patient’s symptoms, underlying conditions, and the desired outcomes in the hospice setting. Each choice considers both therapeutic benefits and the potential side effects relevant to end-of-life care. 

SELECTING THE MOST APPROPRIATE APPETITE STIMULANT 

NONPHARMACOLOGIC APPETITE STIMULATING TECHNIQUES 

In addition to pharmacological interventions, nonpharmacological approaches can play an important role in improving appetite and enhancing the overall eating experience for hospice patients. These strategies are focused on comfort, maintaining a sense of normalcy, and reducing the psychological burden associated with food intake. 

1. Meal Presentation: Offering small, frequent, visually appealing meals can encourage patients to eat more. Avoid overwhelming patients with large portions and instead present nutrient-dense foods in small amounts. 
2. Favorite Foods: Encouraging patients to eat their favorite foods, regardless of nutritional value, can make mealtimes more enjoyable. At the end of life, it’s more important to focus on pleasure than strict dietary restrictions. 
3. Eating Environment: Creating a relaxed and pleasant dining environment can help reduce stress and improve appetite. Eating with family members, playing soft music, and minimizing distractions may enhance the experience. 
4. Oral Care: Regular oral hygiene can improve taste sensation and make eating more enjoyable. Dry mouth, a common issue in hospice patients, can be addressed with moisturizing mouth sprays or rinses. 
5. Timing and Routine: Offering meals when patients are most alert and comfortable, typically earlier in the day, can help stimulate appetite. Establishing a routine for meals can also promote better eating habits.
6. Nutrition Supplement Priming: Drinking one-half can of ensure or any other nutritional supplement 30 minutes before scheduled eating time may help prime GI tract, allowing the patient to consume more than they could have otherwise been able. 

These nonpharmacological methods aim to make the act of eating less burdensome and more aligned with the patient’s comfort and preferences. 

SUMMARY 

Appetite stimulants can play a role in hospice care, primarily in alleviating the psychological and emotional burden of anorexia at the end of life. However, their use must be carefully considered, with attention to the patient's goals of care, the expected benefits, and potential side effects. While they may provide some improvement in appetite, they are unlikely to reverse cachexia or significantly alter the course of a terminal illness. The primary focus of hospice care remains on comfort, and the use of appetite stimulants should be approached with this goal in mind. 

The decision to initiate an appetite stimulant should be based on an individualized assessment, considering factors such as patient distress, family concerns, and the impact of anorexia on quality of life. A careful balance between therapeutic benefits and the burden of side effects is essential. When used appropriately, appetite stimulants can offer modest relief, though their overall impact on quality of life may be limited to emotional well-being rather than physical improvements. 

Hospice clinicians should remain vigilant in monitoring for adverse effects and be ready to discontinue treatment if the risks outweigh the benefits. Ultimately, the goal is to ensure that any intervention, including the use of appetite stimulants, aligns with the principles of hospice care—focusing on patient comfort, dignity, and peace at the end of life. 

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Resources: 

1. Alibhai, S. M. H. (2005). An approach to the management of unintentional weight loss in elderly people. Canadian Medical Association Journal, 172(6), 773–780. https://doi.org/10.1503/cmaj.1031527 
2. Arnold, M. J. (2022). Palliative Care of Patients With Cancer: Guidelines From the National Comprehensive Cancer Network. American Family Physician, 106(1), 102–103. https://www.aafp.org/pubs/afp/issues/2022/0700/practice-guidelines-palliative-care-cancer-patients.html 
3. End of Life Eating Habits. (n.d.). VNS Health. https://www.vnshealth.org/patient-family-support/health-library/eating-patterns-end-of-life/ 
4. Gay, L., Sheth, S., & Horstman, M. J. (2021). Things We Do for No ReasonTM: Prescribing Appetite Stimulants to Hospitalized Older Adults With Unintentional Weight Loss. Journal of Hospital Medicine, October 2021 - Online First. https://doi.org/10.12788/jhm.3652 
5. Hennings, J. M., Heel, S., Lechner, K., Uhr, M., Dose, T., Schaaf, L., Holsboer, F., Lucae, S., Fulda, S., & Kloiber, S. (2019). Effect of mirtazapine on metabolism and energy substrate partitioning in healthy men. JCI Insight, 4(1). https://doi.org/10.1172/jci.insight.123786 
6. Morrow, A. (2007, November 26). How to Recognize When Your Loved One Is Dying. Verywell Health; Verywellhealth. https://www.verywellhealth.com/the-journey-towards-death-1132504