[Total parenteral nutrition for ileus in the palliative phase]

Total parenteral nutrition may be considered for a carefully selected group of palliative patients with ileus. Predictive factors include a strong desire to live, low burden of disease other than the ileus and expected increase in quality of life as a result of starting with total parenteral nutrition. Therapy compliance is required and a strong social network is desirable. Close collaboration between hospital and general practitioners and frequent reviews of the palliative care plan are also required for success.

["Junk-food"-intervention in poisoning delusion]

Case report about a 29-year old US-American patient who suddenly flew to Germany due to a schizoaffektive disorder. During a stay in our psychiatric hospital she refused food, liquid and medication because of fear of being poisoned. After four days her general condition had worsened rapidly so that parenteral nutrition was discussed. Surprisingly her poisoning delusion could be overcome by offering American "Junk-Food". From this moment on compliance in taking of medication improved too, so that renormalisation of her condition was achieved.

Aggressive management of recurrent ovarian cancer--the challenge of individualizing cancer therapy illustrated by a case report

BACKGROUND

In clinical practice, treatment recommendations and the patient's wishes often diverge, facing the physician with difficult choices.

CASE REPORT

The clinical course of a 36-year-old patient with 'platinum-refractory' ovarian cancer is reported. The patient experienced a symptomatic relapse 7 months after debulking surgery and completion of platinum-based first-line chemotherapy. As she had given birth to a son 22 months before diagnosis, she fought with outmost determination against her disease. Her husband supported her, and both asked for maximal therapy, including intensive care treatment for recurrent respiratory tract infections and total parenteral nutrition (TPN). For the patient, it was of major importance to stay with her family and make sure that her son would be able to remember his mother. Problems related to TPN and progression of disease affected her individual perception of quality of life to a much lower extent than expected and perceived by her caretakers. All professional health care providers were more than once very reluctant to continue treatment and only after extensive counseling gave in to the demand of the patient for further treatment, considering the effort futile - only to be surprised by treatment response and recovery. After 3 years of palliation, the tumor was resistant to all cytotoxic regimens and the patient died 2 months after withdrawal of chemotherapy.

CONCLUSION

This case report illustrates that also in the age of evidence-based medicine individualized treatment beyond proven strategies can offer patient benefit. Taking the child's development into account makes it impossible to determine the cost-benefit ratio.

A Systematically Tested Intervention for Managing Reactive Depression

BACKGROUND

Patients and family caregivers repeatedly experience reactive depression that leads to medication errors, mismanagement of chronic disease, and poor self-care. These problems place them at high-risk for malnutrition, infection, heart diseases, and psychiatric sequelae.

OBJECTIVES

A secondary data analysis compared findings across a series of studies to evaluate the acceptability, effectiveness, and cost of a therapeutic writing intervention to reduce reactive depression, a common and frequently recurring adverse symptom.

METHODS

Secondary analysis of data from the series of studies was conducted. Data came from patients requiring lifelong, daily central intravenous catheter infusion of home total parenteral nutrition necessitated by nonmalignant bowel disease and their family caregivers who assist with this complex home care. Variables combined across the studies were pre- and postintervention scores from the Center for Epidemiological Studies-Depression Scale (CES-D), the number of weeks patients wrote in their diaries (adherence), and the written content in the diaries. Content analysis was used to analyze written data. The intervention materials and nurses' time spent were averaged across studies to determine costs.

RESULTS

The weighted average baseline CES-D scores across studies for patients (17.94) and caregivers (15.75) showed the presence of depression. After journal writing had been used for an average of 10.4 weeks across studies, the effect sizes of the between (d =.27) and within (d =.65) patient group scores indicated moderate to large improvement in depression. Themes from written diaries showed that missing out on activities, financial worries, strain related to the severe illness, and the complexity of home care were related to depression across the studies.

CONCLUSIONS

The intervention was acceptable to participants, effective for managing reactive depression, and low in cost. The next steps will address testing for the longitudinal effects of the intervention.

Case study approach to peripherally inserted central catheters

This article looks at the referral of a patient (Mr H) for parenteral nutrition and the subsequent insertion of a peripherally inserted central catheter (PICC) by the nutrition nurse (NN). It explores the issues directly related to the PICC insertion including the route of intravenous access, the ability of the NN to insert the PICC, preparation, communication and consent, and prevention of the mechanical and septic complications of insertion. This case study demonstrates a good technical mastery of PICC insertion in relation to the issues raised. Mr H was satisfied with his care, offering positive feedback at follow-up visits to clinic. Critical analysis of the case study also revealed implications for further development of the role of the NN in ordering the check X-ray and the development of evidence-based standards and guidelines related to this procedure.

Caregiving effectiveness in families managing complex technology at home: replication of a model

BACKGROUND

Original testing of the Caregiving Effectiveness Model, in a randomly drawn national sample (n = 111) of family caregivers, explained variance in the home care outcomes of patient physical condition, technology side effects, and quality of life. The variables in the resulting model reflected the challenges specific to family caregivers managing complex home care for the growing populations of technology-dependent patients.

OBJECTIVE

To seek further empirical verification of the relationships among home care outcomes and the variables in the original trimmed model.

METHOD

Data were collected from family caregivers (n = 31) and adult patients (n = 31) requiring lifelong daily total parenteral nutrition (TPN) infusion technology for nonmalignant bowel disease. Hierarchical regression was used with variables entered in the two stages that coincided with the model configuration of Caregiving and Adaptive concepts, with a criteria of alpha = .05 at a power of > .80.

RESULTS

The model variables explained variance in all four outcomes. Specifically, Caregiving and Adaptive concept variables contributed to the explained variance in quality of life of both caregivers (R2 = .559, F = 4.65, p = .003) and patients (R2 = .464, F = 5.17, p = .04). Variance in patients' physical condition (R2 = .345, F = 6.37, p = .032) and the technological side effects outcomes (R2 = .357, F = 3.60, p = .018) were accounted for by variables in the model.

CONCLUSIONS

In this sample, the Caregiving Effectiveness Model concepts accounted for significant variance in home care outcomes (quality in patients' and caregivers' lives, patients' physical condition, and technological side effect). Longitudinal study of this sample will determine if variables explain variance over time, as in the original model testing.

Total parenteral nutrition (Part 2)

Last week, the author described the controversial history of total parenteral nutrition (TPN) and offered brief guidelines for safe and effective administration (1). She now concludes her overview of TPN by describing the metabolic, pharmacological, mechanical, infection control and psychological considerations which have such an important effect on the therapy.

Anorexia nervosa and total parenteral nutrition

Anorexia nervosa can have a devastating outcome. There is a high rate of treatment failures and recidivism among anorectic patients. Further, it is generally accepted that unless one can effectuate a significant weight gain in these patients, treatment is even more likely to fail. Total parenteral nutrition (TPN) offers an alternative mode of treatment to be used in the armamentarium to successfully treat anorexia nervosa.

[Inpatient psychotherapy of hyperemesis gravidarum--a case report]

Although now there is no doubt about the role of psychosocial factors in hyperemesis gravidarum, remarkably little literature can be found on the subject of psychotherapy and hyperemesis. This may be due to the decreasing number of severe cases, light cases generally do not require treatment. In the past, mostly hypnosis and several different types of supportive psychotherapy were propagated. We are reporting about the trial attempt of treating a patient with hyperemesis gravidarum with in-patient psychotherapy on an internal medicine-psychosomatics ward in tight cooperation with the referring gynaecological clinic. We suggest in-patient psychotherapy as one possibility of treating protracted vomiting in pregnancy.

Feeding the terminally ill: dietitians' attitudes and beliefs

Medical, legal, and bioethical discussions have focused on withholding or withdrawing nourishment from adults who are terminally ill or in persistent vegetative states, yet few discussions have considered the dietitian's role. In June 1990, the Supreme Court upheld an individual's right to refuse life-prolonging procedures, provided those wishes had been clearly documented. This decision, and The American Dietetic Association's 1987 guidelines for feeding the terminally ill, may enable dietitians to evaluate complicated situations regarding feeding and nonfeeding of patients. A survey sent to 590 registered dietitians in The American Dietetic Association's Nutrition Support dietetic practice group resulted in a 42% (n = 250) response rate. In general, dietitians were more willing to discontinue total parenteral nutrition than to discontinue enteral, noninvasive enteral, or oral feedings. They thought that feeding could be discontinued if it causes pain or worsens the condition, if death is imminent, or if the patient has requested that feeding be stopped. University courses and continuing education programs on the ethics and legalities of feeding terminally or critically ill adults will enable dietitians to take active roles in the decision-making process and to promote awareness of relevant issues with patients and families.

Psychosocial issues of nutritional support. A multidisciplinary interpretation

In many cases, initiation of specialized nutritional support is a final attempt at medically managing illness for which other treatments have failed. Patients may have suffered for months or even years with their underlying diseases and are usually aware that poor response to nutritional support and concurrent therapies may lead to surgical intervention or more complex treatment. In some cases, there may be few alternatives left to pursue. For such patients, this paints a very stressful picture. If we as caregivers are empathetic to each patient's situation, we are better able to offer the support that these patients need. Health care professionals must keep patients informed of treatment plans and encourage participation in the planning process--during hospitalization, through the discharge phase, and after hospitalization. We need to pay close attention to those needs, whether nutritional support is short-term during hospitalization, prolonged, or permanent. The health care environment is demanding greater proficiency in cost containment and quality assurance in the delivery of care. Complex patient cases are becoming more difficult to manage as time constraints and resources become more restrictive. The ingenuity and imagination of health care providers trying to find ways to continue providing high-quality and safe care to patients are being tested daily. These worthwhile goals can be met only through cooperation, communication, and support among all levels and disciplines involved with the delivery of care. Feelings of helplessness, dependence, and loss of control can be diminished if health care providers maintain optimistic, confident attitudes, offer positive reinforcement for patients successes, and try to restore hope during this stressful period in patients' lives.

Intellectual and perceptual-motor performance of children receiving prolonged home total parenteral nutrition

Intellectual and perceptual-motor functioning was studied in 12 children receiving prolonged home total parenteral nutrition. Children were between the ages of 4 years 2 months and 7 years 9 months. Average duration of total parenteral nutrition was 52.25 months (SD 15.55) with an average onset of 10.67 months (SD 8.99). Total parenteral nutrition was begun for eight of the children prior to or at approximately their first birthdate. Intelligence was assessed with the Wechsler Preschool and Primary Scale of Intelligence or the Wechsler Intelligence Scale for Children--Revised. Perceptual-motor functioning was measured by the Beery Buktenica Developmental Test of Visual-Motor Integration. All children functioned within the average range of intelligence, but the majority of children evidenced some deficits in perceptual-motor performance. This was particularly true for the older children (greater than or equal to 6 years). Home total parenteral nutrition onset and duration were unrelated to outcome. Medical complications, unrelated to home total parenteral nutrition, requiring lengthy and frequent hospitalizations were highly related to nonverbal intelligence and to perceptual-motor functioning. Although unrelated to perceptual-motor deficits, social class was highly associated with verbal and nonverbal intelligence.

Home parenteral nutrition and the family

When a patient begins home parenteral nutrition (HPN), everyone in the patient's family is affected. In the early stages, the predominant issues are unfamiliarity with the HPN equipment and fear of acute complications. Later, adjustments become necessary in routine family activities such as eating, traveling, and recreation. The indwelling catheter used for parenteral feeding is a source of body-image distortion and anxiety for the patient, his or her sexual partner, and family members in general. The role of the consultation-liaison psychiatrist in the multidisciplinary home hyperalimentation team is described.

Feeding resistance after parenteral hyperalimentation

Infants requiring prolonged hyperalimentation for a variety of conditions may experience difficulty in establishing oral feedings. Indeed, active resistance to oral feeding is often observed. We describe an infant who was deprived of normal oral feedings for the first ten months of life. Because subsequent feeding resistance was apparently due to behavioral and developmental factors, we suggest that the approach to such cases should involve particular attention to these areas. The child development literature and our surgical experience with esophageal atresia give supporting evidence.

Behavioral management concepts with application for home parenteral nutrition patients

The concept of symptom-avoidance behavior is discussed, with particular reference to home intravenous hyperalimentation (HIVH) patients. Symptom-avoidance behavior is explained as a combination of a health behavior model and an expectancy motivational theory leading to a basic outcome, which is satisfactorily avoiding the onset of symptoms. A systematic behavioral assessment method is presented, based on anecdotal cases; it is experimental in nature and can serve as a guide for practitioners who wish to initiate HIVH.

Teaching home parenteral nutrition to patients with limited compliance skills

Information gathered from psychological and behavioral assessment procedures was used to select a teaching approach for two home parenteral nutrition patients with limited abilities to learn--and therefore to comply with--their regimens. A "behavior shaping" procedure, involving the simplification of complex home parenteral nutrition tasks, resulted in significantly improved performance by both patients. Results suggest that these procedures may be applied to other home parenteral nutrition patients, including those without apparent skill deficits.

Home total parenteral nutrition: a psycho-social viewpoint

Home total parenteral nutrition (TPN) usually necessitates major and probably permanent changes in the patient's major and probably changes in the patient's lifestyle. Among the nonmedical, nontechnological issues these patients face are the need to: (1) adhere to prescribed regimens to avoid crises and to control symptoms; (2) alter their self-perceptions; (3) modify their accustomed roles; (4) reorder their priorities and re-think their values; (5) deal with machine and medical center dependency; (6) assign a monetary value to their lives. The emotional and environmental pressures that are the chief issues for these patients include financial, employment, psychological, and interpersonal problems such as depression, anger, anxiety, relief, body image, and self-esteem. Patients on hom TPN are best treated with a clinical team that serves both the patient and family as individuals and as a social system. Services offered include: (1) medical diagnosis, treatment, and rehabilitation; (2) professional and technical support services including pharmacy, dietary, and nursing to teach, demonstrated and monitor self-care, nutrition, and use of the home TPN system; and (3) professional social work services to assist patients and families to deal with the feelings, relationships, environmental pressures, and advocacy needs associated with home TPN.

The treatment of anorexia nervosa with total parenteral nutrition

Treatment outcome of 11 anorectic patients receiving total parenteral nutrition (TPN) is compared with outcome of anorectic patients receiving standard behaviorally oriented inpatient therapy. TPN resulted in significantly more rapid weight gain. Most patients could be successfully weaned from TPN to enteral feeding with continued weight gain. Complications during TPN were common including transaminase elevations and electrolyte imbalance. There was one death in the series. The role of TPN in the management of anorexia nervosa is discussed.

Home parenteral nutrition: the "costs" of patient and family participation

The continued advancements in technology and medicine now make it possible for patients who are nutritional "cripples" to thrive on an outpatient basis through home parenteral nutrition (HPN). Since the social and psychological literature does not yet reflect extensive information on this type of program, this article outlines in detail a successful HPN program and explores the personal factors and needed resources involved in participation in such a program, including the perils of third party reimbursement. Based on experience in evaluating 36 HPN candidates and working with 26 HPN participants, the salient problems and concerns patients and families encounter with HPN therapy are discussed along with suggestions for constructively addressing such issues.

Home parenteral nutrition for the short bowel syndrome. Psychological issues

Home parenteral nutrition (HPN) for the short bowel syndrome represents a treatment modality that raises issues about prolonged machine dependency for living. Psychological reactions are described for patients with inflammatory bowel disorders and anatomical loss of small bowel. Liaison psychiatry involvement with 50 patients in the HPN program has identified such problems as grief reactions, depression, organic brain syndromes, drug dependency, and body image changes as they influence the initial adjustment to the in-hospital phase of HPN learning for patient and family. The importance of family and mental status examination are emphasized in the evaluation of the patient before and during the institution of an PHN program. Outlined are psychological parameters that need to be considered when assessing what factors might impede or enhance the acquisition and use of HPN information.

Psychological aspects of long-term home hyperalimentation

Ten patients (24--66 yr), maintained on ambulatory home intravenous hyperalimentation (HIVH) for 1/2--3 1/4 years, have undergone psychological evaluation. Acceptance of oral deprivation and the inconveniences, restraints, and risks of long-term or life-long HIVH, and the mechanisms for coping with these stresses, varied among this group. At times, the fear related to the HIVH apparatus and its function assumed almost delusional proportions; at other times, the patients acted indifferently or even irresponsibly toward the management of their life-sustaining system. These patients had to cope with public inquisitiveness as well as their own self-consciousness in public. Stress seemed to be related to the patient's prognosis, not only regarding recovery from the primary pathologic process, but also his/her prospects for return of normal gastrointestinal function. Stress reactions also varied among the spouses and families of the patients, and the quality of their psychological support appeared to affect the patient's mental, physical, and social wellbeing significantly. An entirely new spectrum of psychologic and social problems have emerged to challenge the IVH team who successfully manage patients unable to sustain themselves nutritionally. It is imperative that we recognize, prevent, ameliorate, and treat these problems with the same degree of enthusiasm and competence with which we nourish the patients.

Permanent total parenteral nutrition: psychological and social responses of the early stages

Permanent Total Parenteral Nutrition (TPN) is a life-saving but complicated procedure which has profound effects upon the lives of patients and their families, but there is a dearth of information on the the psychosocial consequences of this unique form of therapy. The authors worked with 19 consecutive TPN patients in hospital and after discharge and observed their reactions. It was found that the earliest stages were the most difficult, with anxiety, depression, fear, and negative body image predictable and universal experiences. Major adjustment problems centered around the loss of the basic function, eating. This artificial form of feeding forced multiple alterations in the patients' life styles. Their ability to cope with this intrusive procedure was related to the level of restitution of physical health, ego strength, and the family and hospital support systems. If, in addition to being a life-sustaining procedure, TPN is to restore the psychological stability of patients, all team members must be aware of the psychosocial factors involved.

[The child in digestive resuscitation]

Twenty one children who had total parenteral nutrition followed by a constant infusion into the gastrointestinal tract between the 10th and 90th day of life were studied. When normal feeding is resumed the difficulties are related to the lengths of hospital stay, separation from the parents and the lack of contact with adults more than to the techniques of feeding themselves.

Life without eating or drinking: total parenteral nutrition outside hospital

Total Parenteral Nutrition is no longer a short-term life-saving therapy, but can now provide an alternative permanent nutritional route following loss of small bowel function. Patients placed on the regimen go through several stages during adaptation. Those who have suffered from a chronic debilitating small bowel disease and have previously undergone multiple resections with poor residual nutritional intake, adapt more readily to the regimen than those who have suffered from the combined physical and psychological trauma of sudden massive loss of bowel. The technique has been successful in maintaining one individual in the group studied in good nutritional balance outside hospital for a period of eight years (13). This has been due to combined advances in medical surgical and pharmaceutical techniques (8). Further refinement of the nutritional support system utilized is needed to reduce the duration of the feeding process with the aim of minimizing sleep interruption and resultant fatigue. In elective consideration for TPN, assessment of both personality structure and domestic environmental support is advisable, since the patient generally does not do well in an unsupportive environment with resultant complications and frequent re-hospitalization. Conjoint training of a spouse or family member is essential; and introduction to another patient who has previously adapted well is beneficial. Later, a close liaison should be established with a Home Alimentation Nurse (8-10). The psychiatrist has a potential role in advising the gastroenterologist regarding the suitability of the individual being considered for elective total parenteral nutrition. He has a more definite role in the management of the psychological disturbance, frequently observed as depression, following surgery or later, when it appears secondary to the problems imposed by an altered modus vivendi. The group poses a further special challenge to the psychiatrist due to the unavailability of the normal route of administration of psychotropic drugs when they are indicated.

In addition to the attainment of a relatively normal survival of individuals who have sustained complete loss of small bowel function, TPN offers vistas for research into body nutrition requirements (11) and demands further extensive detailed psychosocial studies of this unique group of individuals.