Albert Barrocas

Gastrostomy Tube Placement in Patients With Advanced Dementia or Near End of Life

Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patients cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.

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 patients 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 patients 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 patients values and cultural and religious diversity in easily understood language, is identified as an innovative tool.

Ethical Considerations in Nutrition Support in Critical Care

Paradoxically, the most ethically troubling decisions in critical care involve therapies of little or no utility. Rarely is the decision to do something questioned by care-givers or family. But the decision to withhold treatment or to discontinue “low yield” therapy is always troubling. Nowhere is this more difficult than with nutrition support. As care-givers, we have a positive duty to feed our patients under most circumstances. It would be unethical to withhold oral feedings without good cause, for example. But what about enteral and, even more troubling, parenteral nutrition? There are clearly circumstances in which continuing to feed a terminal patient, either by feeding tube or intravenously, is simply prolonging death. These issues call for basic consideration of the four tenets of ethics: autonomy, beneficence, non-maleficence, and distributive justice. Bringing the patient’s family to accept withdrawal of nutrition care requires trust, which can be gained only be frequent and honest communication. Even then, cultural, religious, and individual factors may play a large part in the family’s decision. Managing these decisions requires involvement by all of the health care team, as well as by the patient’s family.