Cheryl Monturo

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.

The Artificial Nutrition Debate: Still an Issue... After All These Years

Debate over withdrawal or withholding of artificial nutrition appeared a distant discussion until the furor over the Schiavo case and a Papal Allocation reignited this ethical dilemma. The purpose of this article is to provide a review of the bioethical opinion regarding artificial nutrition, as published in the Hastings Center Report from 1971 until 2007. A clinical and religious history of the evolution and use of artificial nutrition prefaces the review containing common themes and categories framed within a chronology of bioethical and legal events. Finally, an interpretative philosophical discussion is offered on the resurgence of the ethical dilemma concerning withdrawal or withholding of artificial nutrition. Through a combination of classic content analysis and grounded theory, 8 inductively derived categories emerged from a sample of 63 articles/letters with a primary focus on artificial nutrition, enteral nutrition or parenteral nutrition. These categories included illness/treatment trajectory, personhood, family, provider, cost, religion, legal, and ethics and morality. In more than 35 years, surprisingly little has changed with regard to withdrawal or withholding of artificial nutrition. As the Schiavo case revealed, despite a sense in bioethics of a firm consensus about handling the withdrawal of food and water, many are still searching for answers to this dilemma.

Enteral Access Device Selection

Enteral tube feedings have once again emerged as the first choice for nutritional support of the patient on the basis of safety, convenience, and economy. In order to provide adequate nutrition, an appropriate route of administration must be identified. Tube selection will depend on an accurate assessment of the patient, including the duration of therapy, history of abdominal procedures, competency of gag reflex, level of debilitation, gastrointestinal function, and discharge plan. Since placement of these tubes may involve several different physicians, a coordinator is necessary. The clinical specialist in nutrition support may be the appropriate health professional to coordinate this care. With an emphasis on shorter hospital stays, more patients may go home with enteral feeding regimens. The clinical specialist will need to be aware of these changes and become more involved in the initial enteral access device decision to insure appropriate selection.

Clinical Ethics and Nutrition Support Practice: Implications for Practice Change and Curriculum Development

This article was written by Denise B. Schwartz, MS, RD, CNSC, FADA, FAND, FASPEN, a nutrition support coordinator, Providence Saint Joseph Medical Center, Burbank, CA; Nader Armanios, MS, RD, a clinical dietitian, Food and Nutrition Services, Olive View University of California, Los Angeles, Sylmar; Cheryl Monturo, PhD, MBE, an acute care nurse practitioner— board certified, and an assistant chair and associate professor of nursing and John A. Hartford Claire M. Fagin Fellow, College of Health Sciences, West Chester University of Pennsylvania, West Chester; Eric H. Frankel, MSE, PharmD, a board certified nutrition support pharmacist and a clinical pharmacy consultant, West Texas Clinical Pharmacy Associates, Inc, Kansas City, MO, and Lubbock, TX; John R. Wesley, MD, FACS, FAAP, FASPEN, an adjunct professor of Surgery, University of Chicago, Feinberg School of Medicine, Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL; Mayur Patel, MD, chairman, Department of Medicine and ICU committee, Providence Saint Joseph Medical Center, Burbank, CA; Babak Goldman, MD, palliative care director, Providence Saint Joseph Medical Center, Burbank, CA; Gustavo Kliger, MD, chief, Clinical Nutrition Service and Nutrition Support Unit, Austral University Hospital, Buenos Aires, Argentina; and Emily Schwartz, MS, RD, CNSC, a clinical dietitian, Providence Park Hospital, Novi, MI, and a doctoral student, Clinical Nutrition Program, Rutgers, The State University of New Jersey, Newark.