NUTRITIONAL SUPPORT

• Nursing staff assess all patients nutritionally on admission
• refer those ‘at risk’ to ward dietitian
• Review regularly especially during a prolonged inpatient stay
• Details of assessment are in the nursing admission forms

• Provision of food and water by mouth is mandatory basic care
• Some patients wish to eat but are unable to because of difficulty chewing, poor appetite, apathy and depression, or weakness
• offer appetising food of the correct consistency in an appropriate way
• People at the end of their lives often eat little
• accept this natural phenomenon

Consent

• Document in detail the decision-making process at the time it happens
• Obtain consent for any nutritional intervention or withdrawal
• see Consent guideline

• For patients unable/unwilling to eat sufficiently

How

• Obtain advice from ward dietitian
• Review patient regularly
• individual requirements will vary with the changing clinical situation

• If patient not eating sufficiently, consider tube feeding
• nasogastric (NG) tube for short-term
• percutaneous endoscopic gastrostomy (PEG) for long-term
• If patient fails a swallowing assessment, consider a 2 week trial of NG tube feeding
• in end-stage dementia (e.g. when patient fully dependent for all activities of daily living), there is no evidence that artificial tube feeding is of benefit
• tube feeding does not prevent aspiration pneumonia

PEG insertion

Indications

• Dysphagia
• neurological (e.g. stroke)
• mechanical (e.g. oesophageal cancer)
• To supplement inadequate intake where alternative measures have failed:
• cystic fibrosis
• reluctance to eat, only rarely an indication for artificial nutritional support. If in doubt, contact nutrition team

Contraindications

• Absolute
• imminent demise
• ascites
• oesophageal or gastric varices
• advanced dementia
• Relative
• gastric carcinoma
• gastric ulceration
• previous gastric surgery
• physical deformity (e.g. severe kyphoscoliosis)
• clotting disorder/anticoagulation therapy (ensure INR <1.5)
• severe behavioural problems

How

• Refer to ward dietitian and/or nutrition team

Post insertion

• Post-PEG care is detailed in guidelines
• If pain on feeding, prolonged or severe pain, fresh bleeding, external leakage of gastric contents, stop feeding/medication delivery immediately
• seek senior advice urgently regarding CT scan, contrast study/tubogram or surgical review
• Do not discharge patient unless they or their carers are competent in tube care

• If no benefit likely from tube/PEG feeding, consider a trial of comfort feeding even if patient has failed a swallowing assessment
• offer appropriate food of the correct consistency
• discuss risks with patient and/or family/IMCA
• discuss with speech and language therapist and dietitian

• Patients are likely to benefit from total parenteral nutrition (TPN) only if this is needed for at least 7–10 days
• the risks of shorter term feeding outweigh the benefits
• Refer to nutrition team

Indications

• Non-functioning gastrointestinal tract (ileus, obstruction)
• High gut fistulae
• Chylous leaks

Monitoring

• For details on requirements, monitoring and complications of TPN, see Artificial nutritional support in Surgical guidelines

• A professional carer has a duty to prolong life, but not inappropriately to prolong dying
• In ethical and legal terms, there is no difference between withdrawing and withholding artificial nutritional support
• Consider each patient on their own merits and obtain consent

Who

• Withhold tube feeding if it is futile
• e.g. advanced cancer, end-stage dementia
• Withdraw tube feeding if, after a trial of feeding (e.g. nasogastric tube after CVA), there is no recovery and little or no likelihood of recovery or meaningful quality of life

How

• After a decision to withhold/withdraw nutritional support, stop artificial hydration
• a death from malnutrition takes a lot longer than one from dehydration
• If a patient is at risk of aspiration but can still take some food orally, consider ‘comfort feeding’