Decision Making for Alternate Nutrition and Hydration, Part 2

This course is a transcript of the webinar, Decision Making for Alternate Nutrition and Hydration, Part 2, presented by Denise Dougherty, MA, SLP.  Learning Objectives List at least 3 criteria utilized by the medical professional in making recommendations for artificial hydration and nutritionIdentify benefits and burdens of artificial nutrition and hydration versus oral intakeList at least three poor prognostic indicators for placement of artificial hydration and nutrition  Introduction and Overview Let's take a look at the disclosures. We covered those in the bio, so I am not going to spend much time going over those. But I do receive an honorarium from SpeechPathology.com. As for content, in Part Two, we will be looking at why we make recommendations for alternate forms of nutrition/hydration (ANH), based on assessments and the disease process as well as decision-making tools that consider benefits and burdens and poor prognostic indicators. Our documentation must reflect the education effort when the patient and/or family choose to opt out of the recommendations. We will cover what should be included in that documentation. It needs to be more detailed – much more than 144 characters and a dropdown box! The learning objectives for Part Two are that, as a result of the course, you should be able to: list at least three criteria utilized by the medical professional in making recommendations for alternate hydration and nutrition; identify benefits and burdens of ANH versus oral intake; and list at least three poor prognostic indicators for placement of artificial hydration and nutrition. Our agenda is to cover all of the information in the learning objectives. We will be looking at benefits and burdens. There is a nice handout that documents those concepts for you. There are a lot of different decision-making tools and trees that we will cover. Some are very simplistic, while others tend to be a little bit more complicated. We will cover a lot of information about poor prognostic indicators, and informed consent versus informed refusal, and things that you can put into your documentation. Differing Viewpoints In Part 1, we talked about the fact that the patient and the healthcare providers often come together with two different viewpoints. The patient is looking at quality of life. They are also living with cultural and religious values and beliefs. Healthcare providers seem to be coming at this from more of the medical standpoint, and safety with nutrition and hydration. Sometimes we tend to disagree on which recommendation we should actually follow. Many times our patients choose to opt out, and they have the right to do that. Frequently Asked Questions about ANH in Dysphagia Care Frequently asked questions (FAQs) about ANH often center on nutritional status.  Sometimes our patients have poor calorie intake and poor protein intake, and sometimes we forget about the protein aspect. If we are not taking in enough protein, the protein that we are consuming is sent to the vital organs and is not used to heal skin breakdowns. Protein deficiency also affects the function of the intercostal muscles that we use for respiration; it is possible to die from respiratory failure because you have a severe protein deficiency. Other frequently asked questions address medical status.  What is going on with the disorder? We tend to know, as medical professionals, the downward spiral our patients might be facing depending on their diagnosis. We know that when the swallow changes, the patient’s ability to eat safely is going to change. We have that information. FAQs may also look at the behavioral and cognitive status of the patient. We need to be sure that when we are educating a patient, he is able to make decisions; i.e., that he has decision-making capability. Sometimes we may not be aware of where he stands with that capacity, but there are some screens out there that we covered in Part 1 and we will briefly review those in this course as well. There is also the potential that the patient may extubate himself. We see that a lot with dementia patients or patients who have an altered mental status; they are constantly pulling at the nasogastric (NG) tube or the percutaneous endoscopic gastrostomy (PEG) tube and creating damage, and then we have to put it back in again. Medical Ethics There is much to consider when making the recommendation for alternate forms of nutrition and hydration. We look at medical ethics. There is an organization called American Society for Parenteral and Enteral Nutrition (ASPEN) that some dieticians belong to, which has put out some position statements.  We have a couple comments from them in our bullets. The number one concept in medical ethics is that we want to ensure that our recommendations will provide benefits to the patient, not more burdens. Just because we have interventions available does not mean that we need to use them on everybody. We want to make sure that the recommendation is going to be beneficial, and not tax the system too much. If the doctor is unsure whether the patient is in a persistent vegetative state (PVS), they can utilize alternate forms of nutrition/hydration for a trial period until that diagnosis is more certain. PVS is diagnosed around three months after a non-traumatic brain injury, or one year after a traumatic brain injury. It can take some time to come up with this diagnosis - not that it is ours to make - but what do we do in the meantime to provide nutrition and hydration for this individual? When we do make the diagnosis, then it potentially becomes more of a discussion to withdraw treatment that we have already begun providing. We are also supposed to do no harm; in other words, the concept of nonmaleficence. Again, ASPEN has a position statement where they state that withdrawing the alternate forms of nutrition/hydration in a patient who has advanced dementia is ethical if the patient has to be restrained to maintain the placement of the PEG. We need to look at the potential harm to the patient caused by self-extubation and creating damage.   Attitudes Influence of Beliefs and ValuesNot only...