Tube feeding controversial patients: what do dietitians think?

Supplementing Mannan Oligosaccharide Reduces the Passive Transfer of Immunoglobulin G and Improves Antioxidative Capacity, Immunity, and Intestinal Microbiota in Neonatal Goats

Successful establishment of passive immunity (PIT) and regulation of intestinal microbiota are crucial for ruminants to maintain body health and reduce the risk of disease during the neonatal period. Thus, the objective of this study was to investigate the effects of mannan oligosaccharide (MOS) supplementation on passive transfer of immunoglobulin G (IgG), serum inflammatory cytokines and antioxidant levels as well as bacteria composition in the ileal digesta. A total of 14 healthy neonatal Ganxi black goats with similar birth weight (BW: 2.35 ± 0.55 kg) were selected and allocated into two groups, only fed colostrum and milk replacer (CON, n = 7) and supplemented MOS (0.06% of birth BW) in the colostrum and milk replacer (MOS, n = 7). The results indicated that MOS supplementation significantly reduced (p < 0.05) serum IgG level at 3 and 6 h after colostrum feeding. Serum GLP-1 level of goats in the MOS group was significantly lower (p = 0.001) than that in the CON group. Goats in the MOS group had higher serum CAT and lower MDA level than those in the CON group (p < 0.05). Serum anti-inflammatory cytokine level of interleukin 4 (IL-4) was increased (p < 0.05), while pro-inflammatory cytokine IL-6 level was reduced (p < 0.05) in the MOS group when compared with the CON group. In addition, MOS supplementation remarkably increased (p < 0.05) the level of secretory IgA (sIgA) in the ileal digesta. Principal coordinate analysis of 16S rRNA sequence based on Brinary jaccard, Bray curtis, and weighted UniFrac distance of ileal microbiota showed a distinct microbial differentiation between the CON and MOS groups (p < 0.05). The relative abundance of Firmicutes in the MOS group was higher than that in the CON group, while the abundance of Verrucomicrobia was lower in the MOS group than that in the CON group at the phylum level (p < 0.05). The relative abundance of Proteobacteria tended to decrease (p = 0.078) in the MOS group at the phylum level. The results of LEfSe analysis showed that MOS group was characterized by a higher relative abundance of Lactobacillus, while the CON group was represented by a higher relative abundance of Akkermansia and Ruminiclostridium_5. Our findings demonstrated that MOS supplementation during the neonatal period increases antioxidant capacity and reduces the inflammatory response, and promotes IgA secretion and Lactobacillus colonization in the ileum. Thus, MOS induced positive effects are more pronounced in neonatal goats that might be an effective approach to maintain intestinal health and improve the surviving rate of neonatal ruminants.

Clinician's attitude to enteral nutrition with percutaneous endoscopic gastrostomy: a survey in China

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians' opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding.

METHODS

A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses.

RESULTS

Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians' choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80).

CONCLUSIONS

Doctors' insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review

Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.

Perceptions of Healthcare Professionals on the Usage of Percutaneous Endoscopic Gastrostomy in a Teaching Hospital from a Middle-Income South East Asian Country

OBJECTIVE

To explore the perceptions of healthcare professionals' (HCPs) in a South East Asian nation towards percutaneous endoscopic gastrostomy (PEG) feeding.

DESIGN

Semi-structured, qualitative interviews.

SETTINGS

A teaching hospital in Kuala Lumpur, Malaysia.

PARTICIPANTS

A total of 17 healthcare professionals aged 23-43 years, 82% women.

RESULTS

Thematic analysis revealed five themes that represent HCPs' perceptions in relation to the usage of PEG feeding: 1) knowledge of HCPs, 2) communication, 3) understanding among patients, and 4) financial and affordability.

CONCLUSION

The rationale for reluctance towards PEG feeding observed in this regions was explained by lack of education, knowledge, communication, team work, and financial support. Future studies should assess the effects of educational programmes among HCPs and changes in policies to promote affordability on the utilization of PEG feeding in this region.

Registered Dietitians’ Roles in Decision-making Processes For PEG Placement in the Elderly

Purpose: The role of registered dietitians (RDs) in decisionmaking for percutaneous endoscopic gastrostomy (PEG) placement was explored. The ethical climate in their workplace and the relationship between decision-making and the ethical climate were examined.

Methods: The survey included 67 RDs in complex continuing care and long-term care settings in Ontario. Descriptive statistics were used to describe roles, ethical climate, and professional characteristics. Pearson's and nonparametric correlations were used to examine relationships between roles, ethical climate, and professional characteristics.

Results: Among the respondents, 97% thought RDs had a role in decision-making processes. The majority of RDs were usually or always involved in two roles: identifying relevant nutrition issues (91.2%) and discussing feeding options and alternatives (80.7%). Dietitians’ roles in decision-making processes were more extensive when their relationship with physicians was positive (r=0.321, P=0.016), they had adequate knowledge (r=0.465, P<0.001) and adequate skills (r=0.520, P<0.001), and they were more satisfied with their role (r=0.554, P<0.001).

Conclusions: Registered dietitians performed a variety of roles in decision-making processes concerning PEG placement in the elderly. A positive working relationship with physicians, knowledge, skills, and role satisfaction significantly increase RDs’ involvement with patients and families.

How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review

BACKGROUND

Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity.

METHODS AND FINDINGS

We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles.

CONCLUSIONS

When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.

Initiating artificial nutrition support: a clinical judgement analysis

BACKGROUND

Variations in the practice of artificial nutrition are partly a result of the judgements of clinicians. Little is known about these judgements, the decision processes used or the quality of the decisions that arise. The methodology of clinical judgement analysis describes and explains judgemental differences between clinicians and offers a window into why clinician choices sometimes fail to correspond with current best practice guidelines.

METHODS

A clinical judgement analysis with 27 clinicians using two judgement tasks was carried out. Clinicians expressed their 'likelihood of feeding' and 'whether or not they would initiate artificial nutrition support' in response to 54 patient scenarios. Measures of agreement between clinicians, the degree of linear reasoning employed, their judgemental consistency and concordance with National Institute for Health and Clinical Excellence (NICE) guidelines were assessed.

RESULTS

Clinicians' judgements varied substantially both in the amount of information employed and the weighting given to information. Clinicians had only moderate agreement with NICE recommendations and overestimated the need for artificial nutrition support. Suboptimal judgements were consistently applied by clinicians. When clinicians reasoned in more linear ways, their judgements and decisions improved.

CONCLUSIONS

Overestimating the need for artificial nutritional support may inflate health service costs and increase risks for patients unnecessarily. A better understanding by clinicians of the information needed (as well as how to use it) for artificial nutrition support initiation may help improve clinical decision-making.

Preferences of registered dietitians and nurses recommending artificial nutrition and hydration for elderly patients

OBJECTIVE

The study was designed to identify how the beliefs and perceptions of registered dietitians (RDs) affect their decisions to propose artificial nutrition and hydration (ANH) for elderly patients as compared with nurses.

DESIGN

A questionnaire consisting of demographic information, 13 belief statements, and eight patient scenarios requiring ANH was mailed to RDs (n=1,500) and nurses (n=1,500) throughout Florida. Thirteen statements, rated on a 5-point Likert scale, addressed beliefs that influence ANH decisions. Eight scenarios of patients, without an advance directive or surrogate decision maker, were created with variations in age, cognition, and emotion. For each scenario, participants selected a treatment, ANH or hydration, and responded: recommend; not recommend; undecided; or recommend a trial period; if no improvement, stop treatment.

STATISTICAL ANALYSES PERFORMED

To establish reliability and validity, the instruments were pilot-tested with a group of RDs and nurses. Cross tabulations with chi2 tests compared the distribution of responses to the belief statements and scenarios. Statistical significance was P<0.05.

RESULTS

Responses to the belief statement, "when in doubt, feed" differed significantly (P<0.001) between RDs and nurses, all other belief statements were not significantly different. In all eight scenarios, significantly more (P<0.001) RDs recommended ANH than did nurses.

CONCLUSIONS

RDs clearly endorsed feeding when in doubt; therefore, they recommended ANH more than nurses. Nurses, who hesitated to feed when in doubt, were more diverse with their recommendations, either recommending a trial or not recommending ANH. A philosophical difference related to feeding was apparent between RDs and nurses and may affect consistent and quality care in patients without an advance directive or surrogate decision maker.

Percutaneous endoscopic gastrostomy (PEG): the role and perspective of nurses

AIMS AND OBJECTIVES

To study the perspectives of nurses on (i) the process of decision-making regarding the placement of feeding gastrostomies, (ii) their role in the process, (iii) the impact this participation has on them personally and (iv) gastrostomy placement in general.

BACKGROUND

The decision to commit patients to long-term feeding using a gastrostomy tube can be very difficult, particularly when the anticipated benefits are uncertain. Strategies to improve such decision-making are required. Nurses are in an excellent position to provide valuable insights regarding this decision-making and their increased participation in this process might substantially improve it.

DESIGN

A cross-sectional, exploratory design using in-depth semi-structured interviews and a self-administered questionnaire.

METHODS

In-depth semi-structured interviews with 17 nurses experienced in percutaneous endoscopic gastrostomy decision-making were undertaken and analysed.

RESULTS

Individuals making decisions regarding feeding gastrostomy placement were observed to be insufficiently informed regarding the device and the ramifications of its placement. Nurses were perceived to play an important, although underused, role in decisions to commit patients to long-term feeding. Participation in the making of these decisions may be stressful to nurses, particularly when the only result anticipated is the sustaining of a life of poor quality. Sixteen nurses reported that they would not want to have a gastrostomy for themselves if they were unable to maintain some quality of life. Strategies that could improve decision-making were suggested.

CONCLUSIONS

Decision-making could be improved by providing better information to decision makers. A team-orientated approach and more active dialogue with regard to care planning among health professionals, especially between doctors and nurses is needed. Effective decisions regarding feeding gastrostomy placement require adequate resources, especially sufficient time for caregivers to communicate effectively with those who must make these decisions.

RELEVANCE TO CLINICAL PRACTICE

The role of nurses in decision-making regarding commitments to long-term feeding using gastrostomy tubes could be effectively augmented.