Denise B. Schwartz

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.

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 clinicians participation.

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.

Aspiration in a patient receiving enteral nutrition.

This case was selected to illustrate the advantages of an interdisciplinary team approach when the aspiration risks of enteral tube feeding are examined for patients with multisystem involvement. The case reviews a 79-year-old widowed woman with a cervical 6 to 7 spinal cord injury requiring mechanical ventilation and enteral feeding. The patient had multiple complications that prolonged her hospital course and required interdisciplinary involvement of medical, nutrition, nursing, respiratory, and speech pathology services. After an initial stay at another hospital, she was admitted to Providence Saint Joseph Medical Center (PSJMC) Acute Rehabilitation and Intensive Care Units. The patient was transferred home with PSJMC Home Health Services, and her case was part of a continuous quality improvement (CQI) project population group of ventilator-dependent patients. The purpose of the interdisciplinary CQI team was to enhance nutrition intervention, improve patient outcomes, and reduce costs. This teaching case has added to the body of information being evaluated by the CQI team on nutrition intervention of ventilator-dependent patients.

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.

National healthcare decisions day.

The 7th Annual National Healthcare Decisions Day (NHDD) is scheduled for April 16, 2014. This day was initiated to inspire, educate, and empower the public and providers about the importance of advance care planning. NHDD brings focus on the importance of documenting an individual’s wishes for healthcare, including nutrition therapies. The importance of advance care planning in ethical decision making for nutrition support is well documented. Nutrition support clinicians are involved in identifying the need for enteral nutrition (EN) and parenteral nutrition (PN), ordering therapy, administering formulas and solutions, and evaluating and monitoring nutrition therapy. Yet, without appropriate advance care planning, there is a chance that this therapy may not be desired by the individual and is given against his or her wishes. This is most likely to occur if an advance directive is not available for a patient unable to communicate in the hospital, especially without a surrogate decision maker who knows the patient’s wishes. NHDD exists to reduce the frequency of these unfortunate situations. Despite the widespread availability of advance directive forms and resources, implementation rates are poor, communication with healthcare professionals and documentation of preferences remain inadequate, and deficits in advance care planning continue to occur. Resolution of this issue of dealing with life-sustaining medical therapies choices is a multifactorial issue. PN and EN are life-sustaining medical therapies and require a thoughtful decision-making process before the illness and hospitalization, especially when considering these therapies for long-term periods. Also known as artificial nutrition and hydration, these therapies are similar to intubation with subsequent mechanical ventilation in that they are life sustaining. Individuals have the right to decline artificial nutrition during an acute illness or for an extended period. A person’s culture, religion, and values, along with input from family members, may alter his or her view on use of nutrition therapies during an illness and near the end of life. Autonomy is the essential component that must always be considered; yet without an advance directive, the person’s actual wishes may not be known. Incorporating a screening for quality-of-life goals, including a review of the individual’s advance directive, is important prior to recommending nutrition support therapies.

Practice Audit of Nutrition Support Certification

The National Board of Nutrition Support Certification (NBNSC) is an independent credentialing board responsible for administering certification programs in nutrition support. The NBNSC conducted a study (practice audit) of Nutrition Support Professionals (NSP), with the purposes of defining the role of the nutrition support professional and determining the current elements (knowledge or functions) required for competent NSP practice. This article describes the development of the study, results of the study, and use of the information for future certification in nutrition support. A list of the elements required for competent practice was gleaned from a variety of sources. A rating scale was developed to measure the importance of elements required for competent practice and frequency of practice. From this, an online survey instrument was prepared. Surveys were sent to 5964 NSPs; a total of 891 surveys were completed (return rate of 16.8%). There was 98% agreement among the disciplines of the perceived importance of the elements required of competent entry-level NSP practice; that the survey either completely or adequately described these elements; and that it reflected practice by region as well as among various disciplines and work settings. The results of the practice audit demonstrate a common core of practice (95%) across the nutrition support disciplines as well as a universal core of elements believed to be important for competent nutrition support practice. As a result, the NBNSC has developed 1 examination for future nutrition support certification testing and will confer 1 credential, Certified Nutrition Support Clinician (CNSC), to those who pass the exam.

Enteral Nutrition and Dementia Integrating Ethics

This narrative review highlights topics related to feeding patients with dementia, including the use of ethical principles and legal precedents; specifies guidelines and practice recommendations; provides an option to assist in applying the recommendations, such as comfort feedings instead of enteral nutrition; promotes the use of early advance care planning to achieve medical therapies based on an individuals wishes; and provides 3 case studies to demonstrate the clinical application of the information presented in the article. Enteral nutrition guidelines and recommendations have been developed by the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics for individuals with dementia. Predominately these guidelines and recommendations focus on patients with advanced dementia due to the dysphagia and progressive disease process. Despite the research and recommendations to forgo enteral nutrition in advanced dementia, the practice continues. The detailed case studies, integrating an interprofessional approach, provide tools for clinicians to incorporate ethical principles and address the communication aspect when dealing with families and surrogate decision-makers for individuals with advanced dementia.