The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Nutrition support teams: Institution, evolution, and innovation

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States

BACKGROUND

Malnutrition continues to be associated with outcomes in hospitalized patients.

METHODS

An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data.

RESULTS

Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN.

CONCLUSION

Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis

BACKGROUND

Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed.

METHODS

An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted.

RESULTS

The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs.

CONCLUSION

Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19

The coronavirus disease 2019 (COVID‐19) pandemic has impacted all aspects of our population. The “Troubling Trichotomy” of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams?

Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

The Troubling Trichotomy 10 Years Later: Where Are We Now?

A decade ago, "Nutrition Support and The Troubling Trichotomy: A Call To Action" was published in this journal, identifying existing conflicts among technological, ethical, and legal aspects of nutrition support therapy, particularly in terminal or end-of-life situations. Over the past 10 years, the American Society for Parenteral and Enteral Nutrition and others have responded to the action call. A "state of the trichotomy" reveals that while much has been achieved, differences in all 3 aspects will continue to exist due to their dynamic and ever-changing states. The technology arena has made it possible to increase the delivery of nutrition support in alternative settings with the use of telemedicine and social media. Critical/crucial conversations and earlier declarations of individual wishes for care and treatment while having decision-making capacity have been enhanced with the focus on patient-centered and family-centered care. The definition of death as brain death has been challenged in at least one instance. Conflicts between the state's interests and the individual's interests have added to recent legal controversies. Notwithstanding the progress made over the past 10 years, several challenges remain. The future challenges presented by the Troubling Trichotomy can be best confronted if we ACT-Accountability, Communication, and Teamwork. The focus of teamwork should move from multidisciplinary and interdisciplinary teams to transdisciplinary teams, reflecting the shift to function rather than form presented by the new healthcare environment. The transdisciplinary team will be able address the opportunities of the Troubling Trichotomy in the next decade by incorporating the 12 Cs, as detailed in the article.

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 patient's 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 patient's 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 patient's values and cultural and religious diversity in easily understood language, is identified as an innovative tool.

Once upon a storm: Katrina and nutrition support or the lack thereof

Nutrition support teams face many challenges to establish, fund, maintain, and justify their existence. Some of the challenges can be resolved over time. However, the challenge of providing nutrition in general and nutrition support in specific during a natural disaster is void of the luxury of time experienced with the previously delineated challenges. The experience of Methodist Hospital in New Orleans, Louisiana, during Hurricane Katrina in 2005 in providing nutrition and nutrition support is summarized in this invited article. The recollections of various represented disciplines are bolstered by tables and figures that outline the 7 days before and after Katrina. Transdisciplinarity was exhibited through the performance of nontraditional functions or tasks by a variety of professionals who lived 5 days or longer in the “Methodist Island.” Lessons learned and considerations for disaster preparedness as it relates to nutrition and nutrition support as well as general considerations are provided.

Nutrition care of older adults with chronic disease: attitudes and practices of physicians and patients

OBJECTIVES

Eighty percent of older adults have at least one chronic disease. Most conditions could be improved with nutritional intervention. This scientific study assessed physician and patient knowledge of, and behaviors about nutrition, resulting in tools to guide physicians in nutrition management of chronic diseases.

METHODS

Surveys were conducted of 300 practicing physicians and 600 older adults to identify current attitudes and practices regarding the role of nutrition in chronic disease management.

RESULTS

Ninety percent of physicians surveyed recognize the relationship between nutrition and chronic disease. Yet nutrition care occurs only sporadically in primary care settings.

CONCLUSIONS

Most physicians are aware of nutrition in managing chronic disease, but a significant percentage do not routinely include nutrition in their practice. This research led to the development of tools to assist in identifying and managing the nutritional aspects of chronic disease.

Assessing health status in the elderly: the nutrition screening initiative

The recent dramatic growth in the population aged 65 and over is projected to continue well into the 21st century. While improved health status of most aging Americans is also expected, such is not the case in certain vulnerable subgroups at risk for poor health. This includes older women; minority groups; those aged 85 and above; older persons with limited economic resources, those isolated from family and friends; and older persons with impaired physical, cognitive, or emotional status. These factors, plus the cost implications of caring for a rapidly aging population, provided the impetus for the development of the Nutrition Screening Initiative (NSI). Established in 1990, the goal of the NSI is to promote the incorporation of routine nutrition screening and nutritional care into America's health services delivery system. The NSI has devoted its activities toward increasing the awareness of nutritional factors as they relate to the older population.

Nutrition assessment practical approaches

Because of the insidious nature of malnutrition in the elderly and its mimicking the usual aging process, it is important to recognize early warning signs of risks for malnutrition. Because the majority of individuals are encountered at times of a specific event (i.e., illness, injury, surgery, or annual examination) the physician needs to be cognizant of the triggers or alerts of poor nutritional health during history/physical and laboratory examinations for the particular event. Only then will early detection and applicable interventions provide a salutary paradigm shift towards prevention, whether primary, secondary, or tertiary. A high degree of suspicion, a thorough history, and physical examination coupled with pertinent laboratory data can identify the elderly at risk. Those in need of more comprehensive nutrition screen and assessment are examined with the tools developed by the NSI, which encompass not only the routine medical and dietary history and physical exam but also an expansive look at the older individual's psychosocial, functional, socioeconomic, and drug use aspects that are more indirect and significant determinants of risk. Based on parameters from a Level II Screen, measurable indicators are available that provide the nutrition assessment necessary for an overall healthcare plan of selected interventions. Future research should provide more practical, age, sex, and culturally specific nutrition parameters. The main factor in the implementation of a practical, comprehensive geriatric nutrition screening and assessment program is the clinician's imagination and motivation.

Nutrition support, supplementation, and replacement

Nutrition support in acute, chronic, or home care settings can be implemented successfully by the well-informed primary care physician, who often is the first to identify poor nutritional health in his or her patients. Using established protocols for the identification or of risk factors and indicators of malnutrition, specific alerts to the need for nutrition support are presented. The logical approach to nutrition support interventions through four stages representing the gradual increase in complexity and cost, paralleling the progressive inability to use regular foods and the gastrointestinal tract are discussed. Specific, practical measures that can be recommended and implemented by the primary care physician managing the older person are presented. The ethical, legal, and home health aspects of nutrition support in the care of the older American by the primary care physician are also reviewed.

A prospective randomized trial comparing the silver-impregnated collagen cuff with the bedside tunneled subclavian catheter

A prospective study was undertaken to compare the silver-impregnated collagen cuff (Vitacuff) with the bedside tunneled catheter. Fifty patients were randomly assigned to three groups: group I received triple-lumen catheters with Vitacuff application and a semiocclusive dressing material; group II received triple-lumen tunneled catheters with a semiocclusive dressing; and group III received triple-lumen tunneled catheters with collodion as a dressing material. In patients suspected of having central venous catheter sepsis, blood cultures were obtained through the catheter, the catheter was removed, and the tip was cultured semiquantitatively. Central venous catheter sepsis was defined as a positive catheter-tip culture and blood culture for the same organism. No catheter-related sepsis was seen in either the Vitacuff or the tunneled catheters with collodion dressing. In the tunneled catheters with semiocclusive dressing, there was one case of catheter-related sepsis and one case of insertion-site infection. There was also one insertion-site infection in the Vitacuff group, but there was no statistical difference in infection rates between the three groups.

Collodion as a safe, cost-effective dressing for central venous catheters

Catheter-related sepsis continues to be a major problem with the use of central venous catheters. Controversy exists with respect to dressing material and frequency of dressing changes. Collodion is a solution of pyroxylin in a solution of 75% ether and 25% alcohol. Camphor and castor oil are added to create a flexible noncontracting dressing when applied to the skin. We retrospectively reviewed the charts of 34 patients requiring central venous catheters between 1986 and 1988. All catheters were placed via the subclavian approach. Collodion was used as a dressing on all patients. Dressings were not routinely changed. The catheters remained in position an average of 16.5 days. No insertion site became infected; one episode of catheter-related sepsis occurred, and two catheters were inadvertently dislodged. The overall incidence of catheter-related sepsis was 2.9%.

Nutritional considerations in the critically ill

The total care of the critically ill patient must include attention to his nutritional status from the onset of illness. The essential role of protein in body functions must be stressed; unfortunately, it is this essential compartment that will be called upon for gluconeogenesis in stress or starvation. Simple technics of bedside nutritional assessment have been developed and should be familiar to all those who deal with critically ill patients. The multiple technics of optimal nutritional support should become a standard component of the therapeutic armamentarium of those who provide intensive care. The goal must always be to use the GI tract whenever possible, avoiding the numerous complications associated with intravenous nutrition. Care must be taken to avoid CO2 overload of an embarrassed respiratory system by the nutritional support. Whether nutritional or pulmonary support should take priority can usually be resolved by a team approach toward the patient. It is hoped that this superficial review of nutritional support will stimulate the desire for further knowledge of this rapidly changing and interesting aspect of critical care.

Medical, legal and ethical issues in critical care

This report is intended to familiarize the reader with the current legislation concerning state definitions of death, the pertinent judicial decisions concerning termination of life support and the current status of medical/ethical committees. However, it is of paramount importance to all health care personnel to become involved in the resolution of these problems. Current information regarding legal clarity to these issues leaves much to be desired. Unless we wish major decisions that will affect us all to be decided by others, it is strongly suggested that we become directly involved in this process and accept the challenge and the opportunity to influence major legal, ethical, and medical decisions.

Nutritional assessment: indications and applications

The application of objective measures of protein and caloric compartments as well as immunocompetence reveal that approximately 50 percent of hospitalized patients are malnourished. The performance of a nutritional assessment, by a joint effort of hospital personnel, in patients with subclinical or early clinical malnutrition obviates potential complications through early institution of nutritional support. Prudent, logical decisions based on objective data can then be made regarding future patient care resulting in decreased hospitalization, and lower septic and mortality rates.

Nutritional assessment in the community hospital

Innovative technics in the recognition and treatment of malnutrition in hospitalized patients have blossomed in the past decade. A comprehensive nutritional assessment program available in larger institutions has been adapted for use in a community hospital. The procedure of nutritional assessment and its interpretation as employed in 50 hospitalized patients is presented, and therapeutic implications of the assessment are summarized.

The use of stapling devices in the management of postgastrectomy syndromes

By the use of the stapling devices, a large spectrum of postgastrectomy syndromes can be managed with minimal manipulation and dissection, shortened operative time, decreased blood loss and spillage, and reduced morbidity while attaining uniformly good amelioration of symptoms. As others have recommended, the application of these techniques at the primary procedure should be considered. The author's experience in ten primary procedures has been quite gratifying to date.

Catamenial pneumothorax: case report and a review of the literature

Catamenial pneumothorax, a rare but well documented syndrome of recurrent perimenstrual pneumothorax, is being reported with increasing frequency, probably because of increased awareness. Its pathogenesis remains enigmatic but may be associated with hormonal influcences, including the prostaglandins. Its right-sided predilection remains a mystery. the experience of 42 cases in the literature as well as a new case is presented. A rational approach to this interesting syndrome is discussed. Ovulatory suppression should be attempted before thoracotomy and pleurodesis are considered.