Sunday, 11 March 2012

Nutrition support

All Saint's Church, Leamington Spa, Feb 2012
The vast majority of the patients I have been seeing on the wards are one of two types: a) not eating well and requiring either food- or supplement-based prescribing, or b) needing to be fed through a naso-gastric (NG) tube to the stomach via the nose and throat, or percutaneous endoscopic gastrostomy (PEG) tube to the stomach directly through the stomach wall.

A regimen for tube feeding requires a calculation of the patient's likely nutritional requirements for energy, protein and fluid based on their age, sex, likely level of activity, a stress factor according to their clinical condition, and their weight (or more usually an estimated weight because they haven't been weighed as they're supposed to be). Other considerations may be taken into account, such as a prolonged high sodium level in the blood biochemical results, or impaired kidney function. All of this leads to the dietitian making a choice of a type of feed, the amount that the patient should receive, and the rate at which it should be delivered via a pump, which will start at a low level and then increase over a number of days. I document all this in the notes, and all the nurses have to do is follow the instructions.

Compared with drawing up a feed regimen, oral nutritional supplementation is much more complicated. Where the feed, fluid and pump settings are very much under the control of the nursing staff, when it comes to trying to increase a patient's intake in hospital by getting them to eat and drink, there are a whole lot more variables to deal with. The catering department, the food service staff, support workers and nurses all have to come together at mealtimes to provide appetising food and to help frail and sometimes confused and/or recalcitrant patients to eat it. In theory, snacks and drinks are available between meals, including such wonders as cheese and crackers (8g protein and 130 kcal), but the patients are more likely to get a couple of ordinary biscuits (negligible protein and about 70 kcal).

Worse still is if the patient has an impaired swallow, and cannot be given normal food and fluids because of the risk that it will enter the lungs instead of the stomach. Food with modified texture is usually preferable to tube feeding, but trying to maintain sufficient intake from pureed food and fluids thickened to the consistency of custard or syrup is difficult. The very thought of thickened water or tea is enough to put most of us off drinking as much as we should. If this situation persists and the patient is otherwise medically fit for discharge, it may be necessary to draw up a fluid-only plan for their full nutritional requirement of anything up to and sometimes beyond 2000 kcal. This will rely to a great extent on nutritionally complete supplements in order to ensure that vitamin and mineral requirements are covered, because ordinary everyday fluids rarely contain iron, for example.

Even more difficult are those patients who are eating almost nothing but are deemed unsuitable for artificial feeding through a tube. This may be because of a medical condition that makes the endoscopic placing of an NG or PEG tube inappropriate (e.g. oesophageal varices or abdominal ascites), or a condition where artificial feeding has not been found to improve quality of life or clinical outcomes (e.g. dementia). Or because the patient just doesn't want to eat, which is, after all, their right. A referral is often made to a dietitian, because not to do so might be considered neglectful, but a dietitian can't wave a magic wand and make patients eat if they don't want to.

Towards the end of life it is often the case that a patient will stop eating and drinking, and the evidence suggests that clinical dehydration is actually likely to make the process of dying less traumatic. But the ethical dilemmas that arise are no less intractable because of the evidence - what if a patient with dementia starts to have an impaired swallow? Is tube feeding indicated, contributing little to quality of life and likely to cause distress and confusion and be pulled out, or do we offer food and drink orally that may be aspirated and cause chest infections, or will we allow them to starve? Unfortunately there are no easy answers.

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