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

Nutritional Aspects of Wound Care

Malnutrition is a collective term that includes both undernutrition and malnutrition. Malnutrition presents with and without inflammation, is reported in underweight, normal weight, and overweight individuals, and is associated with undesirable alterations in body composition, and diminished functional status. Older adults commonly experience dwindling nutritional status as evidenced by insidious weight loss, insufficient dietary intake, loss of muscle mass, quality, and strength, declining functional status, and other physical and emotional decline indicators. Sustained pressure, acute trauma, malnutrition, and inflammatory-driven chronic conditions increase the risk for skin integrity issues.

Malnutrition management and the application of medical nutrition therapy in hospitalized patients at the end of life

OBJECTIVES

(1) To determine the prevalence of malnutrition risk in hospitalized patients at the end of life (EOL), (2) to evaluate which nutritional interventions are administered in hospitalized end-of-life patients with malnutrition risk and (3) to assess the association of end-of-life care and the administration of medical nutrition therapy in patients with malnutrition risk.

DESIGN

Cross-sectional multi-center study SETTING: Hospital PARTICIPANTS: Hospitalized adult patients MEASUREMENTS: Based on the valid and reliable questionnaire of the Nursing Quality Measurement 2.0 (LPZ), the parameters of demographic data, medical diagnoses, end-of-life phase, care dependency, malnutrition risk according to the Malnutrition Universal Screening Tool (MUST) and nutritional interventions conducted in patients at risk of malnutrition were assessed. Descriptive statistics and statistical tests were conducted. Logistic regression models were established to identify odds ratios (OR) and confidence intervals (CI) for the association of end-of-life care and the provision of medical nutrition therapy. This was done separately for oral nutritional supplements (ONS), enteral nutrition and parenteral nutrition as the respective dependent variables.

RESULTS

Of all 12,947 participants, 706 (5.5%) were in an end-of-life phase. The prevalence of malnutrition risk in end-of-life patients was 41.1% compared to 24.7% in other patients (p < 0.001). End-of-life patients with malnutrition risk received more nutritional interventions than other patients with malnutrition risk. The regression models showed that being at the end of life (CI 1.30, 2.63; p < 0.001), being treated by a dietitian (OR 6.02; CI 4.86, 7.45; p < 0.001), suffering from dementia (OR 1.85; CI 1.10, 3.12; p = 0.02) or cancer (OR 1.56; CI 1.25, 1.96; p < 0.001) increased the chance of receiving oral nutritional supplements. For receiving parenteral nutrition, being at the end of life (OR 1.68; CI 1.04, 2.71; p = 0.04), being treated by a dietitian (OR 5.80; CI 4.07, 8.25; p < 0.001), surgery within the previous two weeks (OR 1.58; CI 1.09, 2.30; p = 0.02), younger age (OR 0.99; CI 0.98, 1.00; p = 0.04), care dependency (OR 0.97; CI 0.96, 0.98; p < 0.001), suffering from a disease of the digestive system (OR 2.92; CI 2.07, 4.11; p < 0.001) or cancer (OR 2.44; CI 1.71, 3.49; p < 0.001) were independent predictors. Being at the end of life did not influence the application of enteral nutrition.

CONCLUSION

This study showed that nutritional interventions are often applied in end-of-life patients admitted to general hospitals. Being at the end of life was positively associated with the application of oral nutritional supplementation and parenteral nutrition. This data does not allow a conclusion about the appropriateness of using medical nutrition therapy in this study sample. Judging the appropriateness of medical nutrition therapy at the end of life is challenging because of the high variability of prognostication as well as the wishes and needs of the specific patients and their relatives that influences the appraisal of adequate interventions. Every decision about nutrition and hydration in end-of-life patients should be a shared decision and be based on advanced care planning principles.

Nutrition strategies for pressure injury management: Implementing the 2019 International Clinical Practice Guideline

Nutrition is an important component in the prevention and treatment of pressure injuries (PIs). The skin is the largest organ of the body, and macronutrients and micronutrients in specific amounts are required to maintain and repair body tissues. The European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel, and the Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: 2019 Clinical Practice Guideline includes nutrition recommendations for PI management. This manuscript identifies the key nutrients required for wound healing, reviews the evidence in the 2019 nutrition recommendations, and translates the recommendations provided into key points to be incorporated into policy and practice that impact patient outcomes.

The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations

GENERAL PURPOSE

To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendations.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Distinguish nutrition and malnutrition, especially as they relate to the development and healing of pressure injuries.2. Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations.3. Identify interventions for improving nutrition status and promoting pressure injury healing.

ABSTRACT

Macro- and micronutrients are required by each organ system in specific amounts to promote the growth, development, maintenance, and repair of body tissues. Specifically, nutrition plays an important role in the prevention and treatment of pressure injuries. The purpose of this manuscript is to review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Nutrition for pressure injury management is discussed in the context of the recommendations.

End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

OBJECTIVE

To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs.

METHODS

A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21).

RESULTS

The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.

Cross-Sectional Nutrition Profile of Palliative Home Care Clients in Ontario and Performance of the interRAI Palliative Care Nutrition Clinical Assessment Protocol

BACKGROUND

The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP).

METHODS

This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance.

RESULTS

Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP.

CONCLUSIONS

Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population.

Role of the Nutrition Support Clinician on a Hospital Bioethics Committee

Hospital bioethics committees comprise a diverse group of healthcare professionals to deal with ethical issues within the institution that arise during patient care. The nutrition support clinicians (NSCs) have an important role on a bioethics committee because of their knowledge and expertise of different nutrition routes and the benefits vs burdens and risks of these modalities, both enteral and parenteral nutrition. Ethics expertise is built on an understanding of ethical principles, when applied in clinical ethics, using critical thinking to prevent ethical dilemmas and to assist in healthcare decision making with a focus on patient-centered care. The NSCs have the opportunity to address ethics during direct patient care with their participation in the intensive care unit interprofessional rounds, family meetings, and surrogate meetings. Evident in ethical dilemmas is often the lack of advance care planning by patients and their family members concerning healthcare wishes for when the individual is unable to communicate their preferences for life-sustaining therapies, including nutrition support. NSCs, as hospital bioethics committee members, are able to support the initiative of National Healthcare Decisions Day to help educate other healthcare clinicians and the public about the importance of advance care planning with communication of healthcare wishes and completion of an advance directive. Components addressed in the article are incorporated into a comprehensive ethics case study, highlighting the role of NSCs.

Nutritional Needs of the Older Adult

Older adults are particularly vulnerable to compromised nutritional status. With advancing age, the consumption of a high-quality, nutritionally dense diet is increasingly essential to optimize health and well-being. Proportionally, macronutrient needs for older adults are similar to younger adults, however overall calorie requirements tend to decline with age. Unique factors influencing food intake should be considered and individualized guidance should be designed to help overcome medical, physical, and social barriers to a healthy diet. The goal for nutrition intervention should ultimately be to promote health and quality of life across the continuum of the aging process.

Development of enteral homemade diets for elderly persons receiving home care and analysis of macro and micronutrient composition

Abstract Objective: the development and analysis of the macro and micronutrient composition of homemade enteral diets. Method: A standard homemade enteral diet was developed at three caloric concentrations - 1500, 1800 and 2100 Kcal. After preparation and testing of viscosity, stability, odor and color, plus evaluation of cost, the chemical composition of the nutrients of the diets were analytically determined. Folic acid, vitamin D and vitamin B12 values were calculated using chemical composition tables. The results were compared with recommended nutritional standards for the elderly. Result: The diets exhibited normal macronutrient distribution. The 1500 caloric level presented some mineral and vitamin deficiencies. Suitable values were obtained at the other caloric levels for all minerals except magnesium. There were appropriate levels of all the vitamins in the 2100 Kcal diet, while vitamin E, D and B6 levels were below the recommended dietary allowances in the 1800 Kcal diet. Conclusion: The standard homemade enteral diets studied can contribute to the food and nutritional safety of elderly persons undergoing home care, if all are supplemented with magnesium and the 1800 Kcal diet is supplemented with vitamin E, D and B6. The 1500 Kcal diet was not nutritionally safe in terms of micronutrients.

The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper

Nutrition and hydration play an important role in preserving skin and tissue viability and in supporting tissue repair for pressure ulcer (PrU) healing. The majority of research investigating the relationship between nutrition and wounds focuses on PrUs. This white paper reviews the 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Nutrition Guidelines and discusses nutrition strategies for PrU management.

Is tube feeding futile in advanced dementia?

It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.

Incorporating Palliative Care Concepts Into Nutrition Practice: Across the Age Spectrum

A practice gap exists between published guidelines and recommendations and actual clinical practice with life-sustaining treatments not always being based on the patient's wishes, including the provision of nutrition support therapies. Closing this gap requires an interdisciplinary approach that can be enhanced by incorporating basic palliative care concepts into nutrition support practice. In the fast-paced process of providing timely and effective medical treatments, communication often suffers and decision making is not always reflective of the patient's quality-of-life goals. The current healthcare clinical ethics model does not yet include optimum use of advance directives and early communication between patients and family members and their healthcare providers about treatment choices, including nutrition support. A collaborative, proactive, integrated process in all healthcare facilities and across levels of care and age groups, together with measurable sustained outcomes, shared best practices, and preventive ethics, will be needed to change the culture of care. Implementation of a better process, including basic palliative care concepts, requires improved communication skills by healthcare professionals. Formalized palliative care consults are warranted early in complex cases. An education technique, as presented in this article, of how clinicians can engage in critical and crucial conversations early with patients and family members, by incorporating the patient's values and cultural and religious diversity in easily understood language, is identified as an innovative tool.

Enteral Nutrition for Older Adults in Healthcare Communities

Older adults living in healthcare communities (HCCs) have multiple comorbidities and are at increased risk of malnutrition and unintended weight loss. Aging affects nearly every system as well as body composition and structure, causing physiological changes that can affect nutrition status. A significant percentage (56%) of residents who live in nursing facilities require extensive help to eat and have dental problems such as ill-fitting dentures, missing teeth, and swallowing problems, which can lead to inadequate caloric intake and unintended weight loss. Alzheimer disease or dementia is prevalent in both nursing facilities and in assisted living/residential care communities, where it affects 45% of older adults. In cognitively impaired residents, most tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources, along with high postinsertion mortality rates within 60 days of insertion. Nursing facilities receiving Medicare or Medicaid funding must abide by state and federal regulations and undergo rigorous surveys while balancing complex decisions related to initial placement of feeding tubes. Healthcare professionals must recognize the importance of establishing nutrition treatment goals that are resident centered and that respect the unique values and personal decisions of the older adult. Informed choice, resident-centered care decisions, and the review of living wills and/or advance directives are essential in the decision-making process. After enteral nutrition is started, healthcare practitioners must carefully review the physician's orders and administer and monitor the resident's tolerance, checking for potential complications.

Integrating patient-centered care and clinical ethics into nutrition practice

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician's participation.