Position of the American Dietetic Association: Ethical and Legal Issues in Nutrition, Hydration, and Feeding

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly was elaborated by nutritionists, nutrologists and hematologists physicians from 15 Brazilians reference centers in hematopoietic stem cell transplantation, in order to emphasize the importancy of nutritional status and the body composition during the treatment, as well as the main characteristics related to patient's nutritional assessment. Establishing the consensus, we intended to improve and standardize the nutritional therapy during the hematopoietic stem cell transplantation. The Consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Artificial Hydration at the End of Life

Initiation or continuation of artificial hydration (AH) at the end of life requires unique considerations. A combination of ethical precedents and medical literature may provide clinical guidance on how to use AH at the end of life. The purpose of this review is to describe the ethical framework for and review current literature relating to the indications, benefits, and risks of AH at the end of life. Provider, patient, and family perspectives will also be discussed.

Registered Dietitians’ Roles in Decision-making Processes For PEG Placement in the Elderly

Purpose: The role of registered dietitians (RDs) in decisionmaking for percutaneous endoscopic gastrostomy (PEG) placement was explored. The ethical climate in their workplace and the relationship between decision-making and the ethical climate were examined.

Methods: The survey included 67 RDs in complex continuing care and long-term care settings in Ontario. Descriptive statistics were used to describe roles, ethical climate, and professional characteristics. Pearson's and nonparametric correlations were used to examine relationships between roles, ethical climate, and professional characteristics.

Results: Among the respondents, 97% thought RDs had a role in decision-making processes. The majority of RDs were usually or always involved in two roles: identifying relevant nutrition issues (91.2%) and discussing feeding options and alternatives (80.7%). Dietitians’ roles in decision-making processes were more extensive when their relationship with physicians was positive (r=0.321, P=0.016), they had adequate knowledge (r=0.465, P<0.001) and adequate skills (r=0.520, P<0.001), and they were more satisfied with their role (r=0.554, P<0.001).

Conclusions: Registered dietitians performed a variety of roles in decision-making processes concerning PEG placement in the elderly. A positive working relationship with physicians, knowledge, skills, and role satisfaction significantly increase RDs’ involvement with patients and families.

Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions.

Regulation of advance directives in Italy: a bad law in the making

PURPOSE

The Advance Directives (ADs) have been adopted in many countries to defend patients' autonomy. In Italy, the role of ADs has recently been the subject of heated debate involving political parties and the Roman Catholic Church. In February 2009, the conservative government coalition presented a bill of law on this issue. It has been passed by the Low Chamber and is now being discussed in the Senate. The purpose of the article is to highlight any possible bill's contradiction with Italian Constitution, Italian Code of Medical Ethics (ICME), and Oviedo Convention contents, relevant for intensivists.

METHODS

Analysis of bill's content in the light of Italian Constitution, ICME, Oviedo Convention articles and in comparison with French legislation regarding end of life (Leonetti law).

RESULTS

In the Authors' point of view the bill's articles -limit the moral and judicial importance of four main issues as informed consent, permanent incapacity, artificial nutrition/hydration, and withdraw/withhold treatments.

CONCLUSIONS

In the Authors' opinion the ADs must represent informed preferences made freely by patients within the relationship with their physicians, as part of an advance care planning. When this relationship develops in accordance with the ICME rules, it contains all of the ethical/professional dimensions to legitimate right choices in each case. The law should draw inspiration from ICME principles, assigning them a juridical power, acknowledging their validity in legitimating end-of-life decisions, and defining a framework of juridical legitimacy for these decisions without infringing on patients' right to autonomy with prescriptions on the care.

Nutrition and physical activity guidelines for cancer survivors

Cancer survivors are often highly motivated to seek information about food choices, physical activity, and dietary supplements to improve their treatment outcomes, quality of life, and overall survival. To address these concerns, the American Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer survivorship to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer. This report summarizes their findings and is intended to present health care providers with the best possible information with which to help cancer survivors and their families make informed choices related to nutrition and physical activity. The report discusses nutrition and physical activity guidelines during the continuum of cancer care, briefly highlighting important issues during cancer treatment and for patients with advanced cancer, but focusing largely on the needs of the population of individuals who are disease free or who have stable disease following their recovery from treatment. It also discusses select nutrition and physical activity issues such as body weight, food choices, food safety, and dietary supplements; issues related to selected cancer sites; and common questions about diet, physical activity, and cancer survivorship.

Artificial nutrition and hydration at the end of life

Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.

Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities

It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. The American Dietetic Association advocates for registered dietitians to assess and evaluate the need for nutrition interventions tailored to each person's medical condition, needs, desires, and rights. Dietetic technicians, registered, assist registered dietitians in the assessment and implementation of individualized nutrition care. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in undernutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. The Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities provides guidance to practitioners on implementation of individualized diets and nutrition care.