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Ordoñez Torres K, Walter Araya A. ¿Es proporcionado suspender la nutrición e hidratación artificial en pacientes con pronóstico incierto? REVISTA LATINOAMERICANA DE BIOÉTICA 2022. [DOI: 10.18359/rlbi.5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Para llevar a cabo esta investigación, se revisó la literatura sobre el caso de Terri Schiavo, paciente que se encontraba en estado vegetativo persistente y quien falleció luego de dos semanas, después de que se le suspendiera su alimentación e hidratación; se validó su diagnóstico y se indagó si fue una paciente terminal, así como también se verificó la evidencia disponible, en relación con la hidratación y nutrición artificial en este tipo de pacientes, para determinar la concordancia de estas medidas. Esta información fue analizada desde la perspectiva nutricional y bioética; en la búsqueda bibliográfica se consultaron las bases de datos Scopus, Scielo y PubMed, con los criterios de búsqueda nutrición e hidratación artificial en pacientes terminales y de pronóstico incierto. Estos hallazgos fueron analizados con el modelo de proporcionalidad terapéutica de Calipari. Por lo anterior, se determinó que la nutrición e hidratación artificial configuraban tratamientos de carácter obligatorio u optativo para Terri. Sin embargo, pese a que no existe información concluyente sobre la nutrición e hidratación artificial en pacientes terminales, ni de pronóstico incierto, se recomienda la evaluación caso a caso de parte del equipo médico, para determinar la proporcionalidad de estos procedimientos en conjunto con el paciente y su familia. Cabe resaltar que son necesarios más estudios para proporcionar mejor evidencia que permita contar con elementos objetivos para una mejor toma de decisiones.
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Pereira AZ, da Cunha SFDC, Grunspun H, Bueno MAS. The Difficult Decision Not to Prescribe Artificial Nutrition by Health Professionals and Family: Bioethical Aspects. Front Nutr 2022; 9:781540. [PMID: 35308279 PMCID: PMC8928268 DOI: 10.3389/fnut.2022.781540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionBioethics and nutrition are essential issues in end of life, advanced dementia, life-sustaining therapies, permanent vegetative status, and unacceptably minimal quality of life. Even though artificially administered nutrition (AAN), for this type of health condition, does not improve quality of life and extension of life, and there is evidence of complications (pulmonary and gastrointestinal), it has been used frequently. It had been easier considering cardiopulmonary resuscitation as an ineffective treatment than AAN for a healthy team and/or family. For this reason, many times, this issue has been forgotten.ObjectivesThis study aimed to discuss bioethical principles and AAN in the involved patients.DiscussionThe AAN has been an essential source of ethical concern and controversy. There is a conceptual doubt about AAN be or not be a medical treatment. It would be a form of nourishment, which constitutes primary care. These principles should be used to guide the decision-making of healthcare professionals in collaboration with patients and their surrogates.ConclusionsThis difficult decision about whether or not to prescribe AAN in patients with a poor prognosis and without benefits should be based on discussions with the bioethics committee, encouraging the use of advanced directives, education, and support for the patient, family, and health team, in addition to the establishment of effective protocols on the subject. All of this would benefit the most important person in this process, the patient.
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Affiliation(s)
- Andrea Z. Pereira
- Oncology and Hematology Department, Israelita Albert Einstein Hospital, São Paulo, Brazil
- Bioethical Committee, Israelita Albert Einstein Hospital, São Paulo, Brazil
- *Correspondence: Andrea Z. Pereira
| | | | - Henrique Grunspun
- Bioethical Committee, Israelita Albert Einstein Hospital, São Paulo, Brazil
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Rochford A. Ethics of providing clinically assisted nutrition and hydration: current issues. Frontline Gastroenterol 2020; 12:128-132. [PMID: 33613944 PMCID: PMC7873535 DOI: 10.1136/flgastro-2019-101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 02/04/2023] Open
Abstract
The provision of clinically assisted nutrition and hydration (CANH) often presents clinicians with ethical dilemmas. As the population grows there is increasing prevalence of patients with conditions such as stroke, dementia, advanced malignancy, cerebral palsy and eating disorders and a greater demand for CANH. It is important that healthcare professionals are familiar with the ethical and legal position for the provision of CANH. In addition, it is important to be aware of the clinical indications, relative contraindications and alternative means of supporting patients for whom CANH is not appropriate; this includes education and training for staff, patients, carers and relatives. The lack of high-quality evidence around clinical outcomes, particularly in the form of randomised clinical trials, and the challenges of accurate prognostication in patients who are approaching the end of life make decisions around the provision of CANH difficult for healthcare professionals.
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Affiliation(s)
- Andrew Rochford
- Gastroenterology, Newham University Hospital Barts Health NHS Trust, London E13 8SL, UK
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Anderson AK, Burke K, Bendle L, Koh M, McCulloch R, Breen M. Artificial nutrition and hydration for children and young people towards end of life: consensus guidelines across four specialist paediatric palliative care centres. BMJ Support Palliat Care 2019; 11:92-100. [PMID: 31630111 DOI: 10.1136/bmjspcare-2019-001909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 11/04/2022]
Abstract
There is a paucity of evidence on the role, use, benefit and challenges of artificial nutrition and hydration (ANH) in children at end of life. Parents express the difficulty they face with making the decision to withdraw ANH. Decision-making on the role of ANH in an individual child requires careful multidisciplinary team deliberation and clear goals of care with children and families. Four paediatric palliative care specialist centres reviewed the current literature and developed consensus guidelines on ANH at end of life. These guidelines seek to provide a practical approach to clinical decision-making on the role of ANH in a child or young person entering the end-of-life phase.
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Affiliation(s)
| | | | - Lizzie Bendle
- Paediatric Palliative Medicine, Evelina London Children's Hospital, London, UK
| | - Michelle Koh
- Paediatrics, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Renee McCulloch
- Paediatric Palliative Medicine, Gt Ormond St Hospital, London, UK
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Sabbouh T, Torbey MT. Malnutrition in Stroke Patients: Risk Factors, Assessment, and Management. Neurocrit Care 2019; 29:374-384. [PMID: 28799021 DOI: 10.1007/s12028-017-0436-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Toni Sabbouh
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Michel T Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA. .,Department of Neurosurgery, The Ohio State University Wexner Medical Center, 410 W. 10th Avenue, Columbus, OH, 43210, USA.
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The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019. J Pediatr Gastroenterol Nutr 2019; 69:239-258. [PMID: 31169666 DOI: 10.1097/mpg.0000000000002379] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety. METHODS A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors. RESULTS A total of 33 recommendations were voted on using the nominal voting technique. CONCLUSIONS JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.
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The Importance of Enteral Nutrition. Dysphagia 2018. [DOI: 10.1007/174_2017_128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sacco J, Virata R. Baby O and the Withdrawal of Life-Sustaining Medical Treatment in the Devastated Neonate: A Review of Clinical, Ethical, and Legal Issues. Am J Hosp Palliat Care 2016; 34:925-930. [PMID: 27729480 DOI: 10.1177/1049909116672177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The discontinuation of life sustaining medical treatment (LSMT) in severely and permanently impaired neonates, especially artificial nutrition and hydration (ANH) is subject to uncertainty and controversy. Definitive clinical guidelines are lacking, clinical research is limited, ethical disagreement is commonplace, and while case and statutory law provide legal underpinning for the practice in defined circumstances, uncertainty in this realm likely influences clinical practice. We use the case of a neurologically devastated neonate to highlight and review these arenas, and show how, using available legal, ethical, and clinical standards and practice, the case of Baby O was resolved, and to underline the need for further research in neonatal palliative care.
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Affiliation(s)
| | - Rebecca Virata
- 2 Santa Monica-UCLA Medical Center and Orthopaedic Hospital, Santa Monica, CA, USA
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Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, Soeters P, Weimann A, Bischoff SC. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016; 35:545-56. [PMID: 26923519 DOI: 10.1016/j.clnu.2016.02.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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Affiliation(s)
- Christiane Druml
- UNESCO Chair on Bioethics at the Medical University of Vienna, Collections and History of Medicine - Josephinum, Medical University of Vienna, Waehringerstrasse 25, A-1090 Vienna, Austria.
| | - Peter E Ballmer
- Department of Medicine, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401 Winterthur, Switzerland.
| | - Wilfred Druml
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Frank Oehmichen
- Department of Early Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01731 Kreischa, Germany.
| | - Alan Shenkin
- Department of Clinical Chemistry, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Jean Leven Building, 6th Floor, Tel Aviv, Israel.
| | - Peter Soeters
- Department of Surgery, Academic Hospital Maastricht, Peter Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Arved Weimann
- Department of General Surgery and Surgical Intensive Care, St Georg Hospital, Delitzscher Straße 141, 04129 Leipzig, Germany.
| | - Stephan C Bischoff
- Department of Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599 Stuttgart, Germany.
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Enteral nutrition in dementia: a systematic review. Nutrients 2015; 7:2456-68. [PMID: 25854831 PMCID: PMC4425154 DOI: 10.3390/nu7042456] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/26/2015] [Accepted: 03/27/2015] [Indexed: 12/12/2022] Open
Abstract
The aim of this systematic review is to evaluate the role of enteral nutrition in dementia. The prevalence of dementia is predicted to rise worldwide partly due to an aging population. People with dementia may experience both cognitive and physical complications that impact on their nutritional intake. Malnutrition and weight loss in dementia correlates with cognitive decline and the progress of the disease. An intervention for long term eating difficulties is the provision of enteral nutrition through a Percutaneous Endoscopic Gastrostomy tube to improve both nutritional parameters and quality of life. Enteral nutrition in dementia has traditionally been discouraged, although further understanding of physical, nutritional and quality of life outcomes are required. The following electronic databases were searched: EBSCO Host, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and Google Scholar for publications from 1st January 2008 and up to and including 1st January 2014. Inclusion criteria included the following outcomes: mortality, aspiration pneumonia, pressure sores, nutritional parameters and quality of life. Each study included separate analysis for patients with a diagnosis of dementia and/or neurological disease. Retrospective and prospective observational studies were included. No differences in mortality were found for patients with dementia, without dementia or other neurological disorders. Risk factors for poor survival included decreased or decreasing serum albumin levels, increasing age or over 80 years and male gender. Evidence regarding pneumonia was limited, although did not impact on mortality. No studies explored pressure sores or quality of life.
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Abstract
The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.
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Schwartz DB, Barrocas A, Wesley JR, Kliger G, Pontes-Arruda A, Márquez HA, James RL, Monturo C, Lysen LK, DiTucci A. Gastrostomy Tube Placement in Patients With Advanced Dementia or Near End of Life. Nutr Clin Pract 2014; 29:829-40. [PMID: 25293595 DOI: 10.1177/0884533614546890] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | | | - John R. Wesley
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Gustavo Kliger
- Clinical Nutrition Service and Nutrition Support Unit, Austral University Hospital, Buenos Aires, Argentina
| | - Alessandro Pontes-Arruda
- Christus University School of Medicine, Fortaleza, Ceara, Brazil
- Baxter Healthcare, Singapore, Singapore
| | | | | | - Cheryl Monturo
- West Chester University of Pennsylvania, West Chester, Pennsylvania
| | | | - Angela DiTucci
- Veterans Affairs Boston Healthcare System–West Roxbury Campus, Boston, Massachusetts
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Wirth R, Smoliner C, Jäger M, Warnecke T, Leischker AH, Dziewas R. Guideline clinical nutrition in patients with stroke. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2013; 5:14. [PMID: 24289189 PMCID: PMC4176491 DOI: 10.1186/2040-7378-5-14] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/22/2013] [Indexed: 01/04/2023]
Abstract
Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke. This guideline is the first chapter of the guideline “Clinical Nutrition in Neurology” of the German Society for Clinical Nutrition (DGEM) which itself is one part of a comprehensive guideline about all areas of Clinical Nutrition. The thirty-one recommendations of the guideline are based on a systematic literature search and review, last updated December 31, 2011. All recommendations were discussed and consented at several consensus conferences with the entire DGEM guideline group. The recommendations underline the importance of an early screening and assessment of dysphagia and give advice for an evidence based and comprehensive nutritional management to avoid aspiration, malnutrition and dehydration.
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Affiliation(s)
- Rainer Wirth
- Department of Internal Medicine and Geriatrics, St, Marien-Hospital Borken, Am Boltenhof 7, D-46325 Borken, Germany.
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Hatano Y, Fujimoto S, Ikka T, Hosokawa T, Fukui K. Oral nutrition or the ability to speak: the choice faced by a cancer survivor. J Pain Symptom Manage 2013. [PMID: 23177722 DOI: 10.1016/j.jpainsymman.2012.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Patients with head and neck cancer often suffer from breathing, speaking, and eating deficits, which negatively affect their quality of life. These patients are often observed to repeatedly contract aspiration pneumonia, resulting in prolonged hospital stays. To help prevent aspiration pneumonia, enteral nutrition is often provided. Although this method helps avoid pneumonia, patients need to give up eating by mouth. Because oral intake of food is closely related to patient quality of life, abandoning eating results in a strong internal conflict. This report describes the case of a cancer patient who experienced repeated aspiration pneumonias after neck surgery. The patient required enteral nutrition to avoid repeated bouts of pneumonia. However, the patient opted for laryngeal closure surgery to regain the ability to take food orally, at the expense of his voice. The patient's choice caused an ethical conflict for the attending medical professionals, highlighting the need for physicians to communicate with their patients to understand their patients' sense of values.
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Affiliation(s)
- Yutaka Hatano
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Medlin S. Recent developments in enteral feeding for adults: an update. ACTA ACUST UNITED AC 2012; 21:1061-2, 1064-7. [DOI: 10.12968/bjon.2012.21.18.1061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Muscaritoli M, Kushta I, Molfino A, Inghilleri M, Sabatelli M, Rossi Fanelli F. Nutritional and metabolic support in patients with amyotrophic lateral sclerosis. Nutrition 2012; 28:959-66. [DOI: 10.1016/j.nut.2012.01.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 01/10/2012] [Accepted: 01/18/2012] [Indexed: 12/12/2022]
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The Importance of Enteral Nutrition. Dysphagia 2012. [DOI: 10.1007/174_2012_578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Monod S, Chiolero R, Büla C, Benaroyo L. Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals. JPEN J Parenter Enteral Nutr 2011; 35:295-302. [PMID: 21527592 DOI: 10.1177/0148607111405338] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.
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Affiliation(s)
- Stéfanie Monod
- Service of Geriatric Medicine and Geriatric Rehabilitation, University of Lausanne Medical Center, Lausanne, Switzerland.
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Rahman M, Evans KE, Arif N, Gorard DA. Mental incapacity in hospitalised patients undergoing percutaneous endoscopic gastrostomy insertion. Clin Nutr 2011; 31:224-9. [PMID: 22047680 DOI: 10.1016/j.clnu.2011.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 10/03/2011] [Accepted: 10/07/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS Decisions to insert percutaneous endoscopic gastrostomy (PEG) tubes may be difficult because patients have serious underlying disease, and the procedure has associated risks. Patients may also lack mental capacity to consent to PEG insertion. This study aimed to prospectively determine the prevalence of mental incapacity in hospitalised patients undergoing PEG insertion. METHODS Mental capacity was assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in 72 consecutive inpatients referred for PEG insertion. Cognitive function was measured using the Mini-Mental State Examination (MMSE). Sixty eight inpatients and 69 outpatients having diagnostic upper gastrointestinal (UGI) endoscopy were similarly studied. RESULTS Thirty nine of the PEG patients had suffered stroke, and none had a primary diagnosis of dementia. Seventy four % (53/72) of inpatients referred for PEG, 22% (15/68) of inpatients having UGI endoscopy, and 3% (2/69) of outpatients having UGI endoscopy, lacked mental capacity, p < 0.001. MMSE scores were normal in just 18% of inpatients having PEG, in 72% of inpatients having UGI endoscopy, and in 91% of outpatients having UGI endoscopy, p < 0.001. CONCLUSION Amongst inpatients undergoing PEG insertion there is a high prevalence (three-quarters patients) of mental incapacity to consent to this important intervention. Decisions have to be made on behalf of most inpatients referred for PEG insertion.
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Affiliation(s)
- M Rahman
- Wycombe Hospital, Queen Alexandra Road, High Wycombe, Bucks HP11 2TT, United Kingdom
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Braun J, Bein T, Wiese CHR, Graf BM, Zausig YA. [Enteral feeding tubes for critically ill patients]. Anaesthesist 2011; 60:352-65. [PMID: 21136033 DOI: 10.1007/s00101-010-1800-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The use of enteral feeding tubes is an important part of early enteral feeding in intensive care medicine. In other faculties with non-critically ill patients, such as (oncologic) surgery, neurology, paediatrics or even in palliative care medicine feeding tubes are used under various circumstances as a temporary or definite solution. The advantage of enteral feeding tubes is the almost physiologic administration of nutrition, liquids and medication. Enteral nutrition is thought to be associated with a reduced infection rate, increased mucosal function, improved immunologic function, reduced length of hospital stay and reduced costs. However, the insertion and use of feeding tubes is potentially dangerous and may be associated with life-threatening complications (bleeding, perforation, peritonitis, etc.). Therefore, the following article will give a summary of the different types of enteral feeding tubes and their range of application. Additionally, a critical look on indication and contraindication is given as well as how to insert an enteral feeding tube.
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Affiliation(s)
- J Braun
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, Germany
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Malmgren A, Hede GW, Karlström B, Cederholm T, Lundquist P, Wirén M, Faxén-Irving G. Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food Nutr Res 2011; 55:6037. [PMID: 21799666 PMCID: PMC3144742 DOI: 10.3402/fnr.v55i0.6037] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/13/2011] [Accepted: 06/23/2011] [Indexed: 11/30/2022] Open
Abstract
Background Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure. Objective The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years. Design and Methods A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy. Results Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia. Conclusions Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly.
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Affiliation(s)
- Anna Malmgren
- Department of Surgical and Medical Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
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Toth J. Development of the Basic Knowledge Assessment Tool for Medical-Surgical Nursing (MED-SURG BKAT) © and implications for in-service educators and managers. Nurs Forum 2011; 46:110-116. [PMID: 21517884 DOI: 10.1111/j.1744-6198.2011.00216.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
UNLABELLED BACKGROUND OF THE PROBLEM: Medical-surgical nursing is now the largest specialty in acute care, and needs an objective measure of basic knowledge necessary to provide safe care to patients. The Joint Commission on Accreditation of Healthcare Organizations noted that healthcare organizations have in the past relied on education and experience to support competence, but an increasing number are seeking objective measures of a nurse's knowledge that is required for safe practice. The American Nurses Association adds that safe practice is both a professional and a moral responsibility. PROBLEM A review of the literature failed to locate a standardized test of basic knowledge in medical-surgical nursing. In-service educators and managers need such a test to facilitate orientation programs, and as a way to safely decrease the length of orientation for new employees with previous experience in medical-surgical nursing. METHODS The purpose of the study was to develop a valid and reliable test to measure basic knowledge in medical-surgical nursing. FINDINGS The Basic Knowledge Assessment Tool for Medical-Surgical nursing was developed with support for its validity and reliability.
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Affiliation(s)
- Jean Toth
- The Catholic University of America, School of Nursing, Washington, DC 20064, USA.
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Abstract
Artificial nutrition and hydration continue to stimulate debate among physicians and in the wider world. This review aims to give those involved in providing nutrition support the necessary tools to be confident in making decisions in individual cases. It examines basic ethical principles and suggests a structured approach to ensure all the relevant factors are considered in making decisions. The current legal context and in particular the provisions of the Mental Capacity Act 2005 relating to nutrition support are discussed. The review concludes by applying the ethical approach suggested to some clinical examples, demonstrating the decision making process.
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Orrevall Y, Tishelman C, Permert J, Cederholm T. The use of artificial nutrition among cancer patients enrolled in palliative home care services. Palliat Med 2009; 23:556-64. [PMID: 19477887 DOI: 10.1177/0269216309105811] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this study, patients' views and experiences of using home artificial nutrition, and factors associated with use of home parenteral nutrition (HPN) were investigated. Structured telephone interviews with 620 cancer patients enrolled in 21 palliative home care services were analysed. HPN was more common (11%) than home enteral tube feeding (HETF, 3%). Home artificial nutrition (including HPN and HETF) was usually introduced more than four months before death. Three of four HPN recipients also had oral food intake. HPN use was associated with eating difficulties, nausea/vomiting, and fatigue rather than gastrointestinal problems per se. HETF was generally used for patients with problems related to oesophagus and head and neck tumours. In conclusion the results suggest that, contrary to existing guidelines, HPN is used to supplement oral intake, and not only for patients with a non-functioning gastrointestinal tract.
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Affiliation(s)
- Y Orrevall
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
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The first nutritionDay in nursing homes: Participation may improve malnutrition awareness. Clin Nutr 2009; 28:109-16. [DOI: 10.1016/j.clnu.2009.01.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 12/18/2008] [Accepted: 01/31/2009] [Indexed: 11/21/2022]
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Nutritional support and risk status among cancer patients in palliative home care services. Support Care Cancer 2008; 17:153-61. [DOI: 10.1007/s00520-008-0467-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 04/30/2008] [Indexed: 10/22/2022]
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Abstract
Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia. While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube. To view an accompanying online video, go to http://links.lww.com/A226.
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Hokpins B, Jonnalagadda SS. The review by Koretz. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 2008; 108:220-225. [PMID: 18237566 DOI: 10.1016/j.jada.2007.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Hébuterne X. La lettre du président : faut-il envisager la nutrition artificielle à domicile chez un malade dépendant ? NUTR CLIN METAB 2006. [DOI: 10.1016/j.nupar.2006.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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