Julie O’Sullivan Maillet

Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. 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 patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitians understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.

The Meaning of Food and Eating among Home Parenteral Nutrition–Dependent Adults with Intestinal Failure: A Qualitative Inquiry

Using content and interpretative phenomenological analysis, we explored the meaning of food and eating from the perspective of adults receiving home parenteral nutrition (PN). The aim of this research was to obtain a deeper understanding of how issues related to food and eating influence quality of life (QOL). Semistructured telephone interviews were conducted between May 2006 and January 2007 with 24 adults with intestinal failure and home PN dependency. The analysis revealed themes relevant to eating behaviors, hunger and thirst, strategies for dining in restaurants, and a perception of wasting money because of malabsorbed food. Three patterns of eating emerged: eating for survival, eating for health benefits, and eating for socialization. A proposed model illustrates how these eating patterns are linked to QOL. Being able to eat and enjoy food is an important ingredient for good self-reported QOL. Measurements of QOL for this population may be enhanced with inclusion of a food and eating domain. The social and emotional context of food and mealtimes is an important component to address in the nutrition care plan for PN-dependent adults.

Role of Registered Dietitians in Dysphagia Screening

OBJECTIVE To examine the ability of registered dietitians to identify patients at risk for dysphagia and make appropriate diet/feeding recommendations in comparison with the speech-language pathologist, and to determine screening criteria for the registered dietitian to use for prediction of dysphagia risk. DESIGN The dietitian and speech-language pathologist performed dysphagia screening on subjects independently through questioning and/or mealtime observation to identify signs and symptoms of dysphagia. Presence of dysphagia risk and diet/feeding recommendations were determined and results from the dietitian and speech-language pathologist were compared. SUBJECTS/SETTING Thirty-four patients admitted during a 2-month period to a neuroscience unit at an urban teaching hospital were analyzed prospectively. STATISTICAL ANALYSES PERFORMED kappa Statistics were used to assess agreement between the dietitian and speech-language pathologist. A kappa level of less than 0.4 indicated weak agreement, 0.4 to 0.7 indicated moderate agreement, and greater than 0.7 indicated strong agreement. Logistic regression methods were used to evaluate screening criteria as potential predictors of dysphagia risk. RESULTS Moderate agreement (0.61) was found between the dietitian and speech-language pathologist in determination of dysphagia risk. The dietitian predicted the ability of the patient to consume an oral diet with strong agreement with the speech-language pathologist (1.0); various diet consistencies with moderate agreement (0.61); and the need for liquid restrictions with strong agreement (1.0). The most significant screening variables for prediction of dysphagia risk (P < .05) were age (P = .018), history of dysphagia (P = .042), difficulty swallowing solids (P = .0007), observed facial weakness (P < .0001), and a change in voice quality (P = .0007). Self-reported screening variables significantly related to dysphagia risk included drooling of liquids (P = .0009) and solids (P = .0080), facial weakness (P = .0006), change in voice quality (P = .0010), and prolonged eating time (P = .0157). APPLICATIONS/CONCLUSIONS Dietitians can effectively identify patients with dysphagia. Screening for dysphagia can be implemented as part of standard nutrition assessments and may aid in decreasing dysphagia-related complications.

Identifying Components of Advanced-Level Clinical Nutrition Practice: A Delphi Study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a masters degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

Position of The American Dietetic Association: Legal and Ethical Issues in Feeding Permanently Unconscious Patients

Health care team members, including the dietitian, must set patient-centered treatment goals that are handled individually and that respect the unique values and personal decision of the patient. The patients expressed desire is the primary guide for determining the extent of nutrition and hydration once the patient is diagnosed as being in a PVS. Within the extent of the law, the family should share decision making when the patients preference is not stated and the family is in agreement about medical care. The health care team will need to discuss with the family as needed the issues of ethics, values, religious guidelines, and pastoral advice. If the patients choice is feeding, the dietitian will ensure that the composition of the feeding promotes nutritional health. If the patients choice is cessation of feeding, the dietitian should explain what is known about the duration of time between cessation of feeding and death. Sensitivity to the familys needs and responsiveness to their questions are imperative in both scenarios. Within institutions, the ethics committee should help establish and implement defined written guidelines for care of the permanently unconscious. The dietitian should be required to be a member of or consultant to such a committee and should serve an integral role in development of institutional policy. The dietitian must provide education about nutrition and hydration issues, serve as a patient advocate, and participate in the legal and ethical issues regarding feeding. The dietetics community is involved in the legislative arena at the state and local level to promote the use of advanced directives and to affect legislative and societal changes that result in appropriate care for patients in a PVS.

Personal and professional beliefs and practices regarding herbal medicine among the full time faculty of the newark-based schools of the university of medicine and dentistry of new jersey.

Background: The use of alternative and herbal medicine is increasing among the general population in the United States. The use of herbal medicine by health care professionals has not been documented. Health care professionals tend to base personal and professional practices on scientific research and facts. This population interacts with the public and with health care students. Therefore, personal and professional practices will impact these audiences. Methods: A survey was distributed to all faculty members of the University of Medicine and Dentistry of New Jersey via interoffice mail. A total of 904 surveys were sent. Statistical analyses included descriptive analysis of personal and professional practice regarding herbal medicine and χ2 analysis of the relationship between personal and professional practices regarding herbal medicine. Significance was set at alpha <.05. Results: The overall response rate was 51%. Approximately one-third (29.6%, n = 134) of the population reported personal use of herbal medicine, 22.1% (n = 42) of the population who provide patient care recommend herbal medicine, 9.4% (n = 36) of those involved in teaching include herbal medicine in coursework, and 1.1% of the population were involved in research on herbs. Respondents who use herbal medicine were more likely to recommend herbs to patients (p < .0001); likewise, users of herbal medicine were more likely to teach students about herbal medicine (p = .001). Conclusions: The results support the hypothesis that personal beliefs and practices do impact professional practices within the clinical and academic settings of the university.

Multivitamin/Mineral supplementation does not affect standardized assessment of academic performance in elementary school children.

Limited research suggests that micronutrient supplementation may have a positive effect on the academic performance and behavior of school-aged children. To determine the effect of multivitamin/mineral supplementation on academic performance, students in grades three through six (approximate age range=8 to 12 years old) were recruited from 37 parochial schools in northern New Jersey to participate in a double-blind, placebo-controlled clinical trial conducted during the 2004-2005 academic school year. Participants were randomized to receive either a standard childrens multivitamin/mineral supplement (MVM) or a placebo. MVM or placebo was administered in school only during lunch or snack period by a teacher or study personnel who were blinded to group assignment. The main outcome measured was change in scores on Terra Nova, a standardized achievement test administered by the State of New Jersey, at the beginning of March 2005 compared to March 2004. Compared with placebo, participants receiving MVM supplements showed no statistically significant improvement for Terra Nova National Percentile total scores by treatment assignment or for any of the subject area scores using repeated measures analysis of variance. No significant improvements were observed in secondary end points: number of days absent from school, tardiness, or grade point average. In conclusion, the in-school daily consumption of an MVM supplement by third- through sixth-grade inner-city children did not lead to improved school performance based upon standardized testing, grade point average, and absenteeism.

Framework for Analyzing Supply and Demand for Specialist and Advanced Practice Registered Dietitians

The number of credentialed dietetics specialists--approximately 15% of the profession--is proportionately higher than those in other allied health and nursing professions. Credentialed specialists seem to receive greater compensation earlier in their career, but this advantage neutralizes as length of time in the profession increases. A larger proportion of younger registered dietitians (RDs) are specialists, which may mean an increase in supply of specialists in the future. There is considerable interest in creation of health promotion and foodservice management credentials. Consideration should be given to collaborating with other organizations to explore new models of recognition or credentialing for narrow areas of focus. Creating a methodology that can differentiate the tasks and approaches to practice that are unique to advanced practitioners compared with specialists has been a challenge. Prior research has not succeeded in identifying the differences in what advanced practitioners do. Future research to isolate advanced practice must take practice approach into account. A new, research-based, credential for advanced practitioners is possible, or a recognition program for advanced practice RDs could be considered. Precise supply and demand for specialty and advanced practice RDs cannot be measured. Thus, in this technical article, the authors share the available information regarding supply and demand with regard to dietetics specialists and advanced practitioners. It seems there are distinctions among the various levels of practice and recognition of their value to the profession and to the health of the public.