Stopping Eating and Drinking by Advance Directives (SED by AD) in Assisted Living and Nursing Homes.

The Ethics Subcommittee of AMDA-The Society for Post-Acute and Long-Term Care Medicine ("The Society") presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice-the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability-is the decisive principle in this controversy. We also suggest that implementing SED by AD can violate a physician's obligation to beneficence and nonmaleficence. On the other hand, we identify with the families of our patients who see the refusal to follow an advance directive as an injustice of the highest order. In the end, The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive. If, on the other hand, one refuses food and fluid to a resident who still accepts food, one risks practicing an injustice against that person as they are now. Recognizing that we have the greatest responsibility to our patients as they present to us in the residential setting, The Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead, a policy of comfort feeding for those with advanced dementia.

Negative prompts aimed at maintaining eating independence.

BACKGROUND: Psychological abuse of older people is difficult to recognise; specifically, nursing home residents have been documented to be at higher risk of psychological abuse during daily care, such as during feeding. Healthcare professionals adopt positive and negative verbal prompts to maintain residents' eating independence; however, negative prompts' purposes and implications have never been discussed to date. RESEARCH AIMS: To critically analyse negative verbal prompts given during mealtimes as forms of abuse of older individuals and violation of ethical principles. RESEARCH DESIGN: This is a secondary analysis of three cases of negative prompts that emerged in a large descriptive study based upon focus group methodology and involving 13 nursing homes and 54 healthcare professionals. PARTICIPANTS AND RESEARCH CONTEXT: This study included 3 out of 13 nursing homes caring for residents with moderate/severe functional dependence in self-feeding mainly due to dementia; in these nursing homes, we conducted three focus groups and 13 healthcare professionals participated. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after being approved by the Review Board of the Trust. FINDINGS: With the intent of maintaining self-feeding independence, negative verbal prompts have been reported as being used by nursing home teams. By critically analysing these negative prompts, it turned out they could trigger intimidation, depression and anxiety and thus could be considered as forms of abuse; moreover, negative prompts can threaten the ethical principles of (1) autonomy using a paternalist approach, (2) beneficence and non-maleficence as with the intent to act in the best interests of residents (to maintain self-feeding independence) they are harmed in their dignity and (3) justice, given that residents who received negative prompts are treated differently from those who received positive prompts. DISCUSSION: Eating should be a pleasant experience with a positive impact on physiological, psychological and social well-being. However, negative prompting can lead to abuse and violation of basic ethical principles, destroying the healthcare professional resident and relative relationships strongly dependent on trust. CONCLUSION: Negative verbal prompting must be avoided.

Adolescents' lived experiences of making health choices: an ethical point of view.

This study describes and interprets adolescents' lived experiences of their rights, duties and responsibilities in relation to their health choices. Fourteen focus group interviews with 67 adolescents aged 15 and 16 were conducted and analysed using the phenomenological hermeneutical method. Adolescents' lived experiences of their rights in relation to their health choices were described as things that were allowed. Duties and responsibilities were perceived as something that they were required to carry out for their own health or other people's health. Although their experiences of rights, duties and responsibilities overlapped, they referred to different aspects of their health choices. Adolescents viewed their rights, duties and responsibilities in the wider context, with parents and society defining their opportunities to make independent choices. We found that ethical considerations influenced adolescents' choices and, the opportunities to exercise their rights, duties and responsibilities varied. Further consideration and recognition of these issues are needed.

The Impact of Trained Volunteer Mealtime Assistants on Dietary Intake and Satisfaction with Mealtime Care in Adult Hospital Inpatients: A Systematic Review.

BACKGROUND: Malnutrition is common in hospital inpatients and is associated with increased morbidity and mortality. Insufficient assistance at mealtimes can contribute to this and therefore trained volunteer mealtime assistants may be of benefit. OBJECTIVES: To identify and review the current evidence for the impact of trained volunteer mealtime assistants on dietary intake and satisfaction with mealtime care in adult hospital inpatients. METHODS: A systematic search of Medline, Embase and CINAHL was conducted to identify relevant articles. Articles of any methodology were considered. Quality assessment and data extraction were carried out by two reviewers independently. PARTICIPANTS: Participants were inpatients in a hospital setting, including rehabilitation units. Participants in long term care facilities were excluded. INTERVENTION: Articles that examined the effect of trained volunteer mealtime assistants on nutritional outcomes or satisfaction with mealtime care were included. RESULTS: 5576 articles were identified, of which 14 were included in the review. Nine were small research studies and five were quality improvement initiatives. The quality of eight studies was moderate, with one study being of lower quality. Eight articles reported dietary intake and seven demonstrated an improvement, with protein intakes at volunteer mealtimes increasing by 4.3g-10.1g and energy intakes by 44-105kcal. Ten articles reported positive staff, patient and volunteer feedback. No adverse events were reported. CONCLUSION: There is evidence from small studies and improvement projects that trained volunteer mealtime assistants are safe and improve satisfaction with mealtime care in hospital inpatients, although evidence for an effect on dietary intake was less consistent. Larger studies with robust methodology are required to confirm this.

Coping with unpleasant knowledge: Meat eating among students of environmental studies.

This paper presents qualitative research on the attitudes and behaviors of environmental studies graduate students toward meat eating, and their strategies for coping with the cognitive dissonance induced by the issues related to meat eating and production. The research draws on theoretical and empirical research on the issue of meat eating and the psychological processes involved in it, and by analyzing in-depth interviews it reveals that these students exhibit partially different coping strategies than what studies on general population show, as a result of their awareness and their social circle. The results show that even though these people do not usually regard meat eating as wrong or undesirable in principle, they are well aware of the ethical and environmental issues related to it. In their attitudes and behavior the students are significantly influenced by their friends and fellow students amongst whom they perceive avoiding meat as a social norm. A generalization of the results suggests that the psychological dynamics of meat eating among environmentally informed and engaged people in general may be different than in general population. Further research into this group of people is proposed, most importantly from a socio-cultural point of view.

Understanding Urban Demand for Wild Meat in Vietnam: Implications for Conservation Actions.

Vietnam is a significant consumer of wildlife, particularly wild meat, in urban restaurant settings. To meet this demand, poaching of wildlife is widespread, threatening regional and international biodiversity. Previous interventions to tackle illegal and potentially unsustainable consumption of wild meat in Vietnam have generally focused on limiting supply. While critical, they have been impeded by a lack of resources, the presence of increasingly organised criminal networks and corruption. Attention is, therefore, turning to the consumer, but a paucity of research investigating consumer demand for wild meat will impede the creation of effective consumer-centred interventions. Here we used a mixed-methods research approach comprising a hypothetical choice modelling survey and qualitative interviews to explore the drivers of wild meat consumption and consumer preferences among residents of Ho Chi Minh City, Vietnam. Our findings indicate that demand for wild meat is heterogeneous and highly context specific. Wild-sourced, rare, and expensive wild meat-types are eaten by those situated towards the top of the societal hierarchy to convey wealth and status and are commonly consumed in lucrative business contexts. Cheaper, legal and farmed substitutes for wild-sourced meats are also consumed, but typically in more casual consumption or social drinking settings. We explore the implications of our results for current conservation interventions in Vietnam that attempt to tackle illegal and potentially unsustainable trade in and consumption of wild meat and detail how our research informs future consumer-centric conservation actions.

'You can't be forcing food down 'em': Nursing home carers' perceptions of residents' dining needs.

Malnutrition is a life-threatening condition among older people living in nursing care homes. This qualitative analysis of interview data from five care staff aimed to understand their perceptions of 'caring for' residents' nutritional needs. Tensions in the delivery of care and institutionalisation and disempowerment were identified. Despite carers' good intentions, they often failed to recognise the importance of the psychosocial aspects of mealtimes. Staff shortages, routine-driven, medically based working practices and residents' resistance to institutionalisation emerged as barriers to quality caregiving. The findings indicate that the relational aspects of care are constrained by social, structural and ideological contexts.

Development of the HELIUS food frequency questionnaires: ethnic-specific questionnaires to assess the diet of a multiethnic population in The Netherlands.

OBJECTIVES: Ethnic minorities are often not included in studies of diet and health because of a lack of validated instruments to assess their habitual diets. Given the increased ethnic diversity in many high-income countries, insight into the diets of ethnic minorities is needed for the development of nutritional policies and interventions. In this paper, we describe the development of ethnic-specific food frequency questionnaires (FFQs) to study the diets of Surinamese (African and South Asian), Turkish, Moroccan and ethnic Dutch residents of The Netherlands. METHODS: An existing Dutch FFQ was adapted and formed the basis for three new FFQs. Information on food intake was obtained from single 24 h recalls. Food items were selected according to their percentage contribution to and variance in absolute nutrient intake of the respective ethnic groups. A nutrient database for each FFQ was constructed, consisting of data from the Dutch Food Composition table; data on ethnic foods were based on new chemical analyses and available international data. RESULTS: We developed four ethnic-specific FFQs using a standardised approach that included ~200 food items each and that covered more than 90% of the intake of the main nutrients of interest. CONCLUSIONS: The developed FFQs will enable standardised and comparable assessment of the diet of five different ethnic groups and provide insight into the role of diet in differences in health between ethnic groups. The methodology described in this paper and the choices made during the development phase may be useful in developing similar FFQs in other settings.

Underlying differences between conscientious omnivores and vegetarians in the evaluation of meat and animals.

As criticisms of factory farming continue to mount, an increasing number of individuals have changed their existing dietary practices. Perhaps the two most important options for those reacting against industrial farming are (1) vegetarianism/veganism (i.e., veg*nism), the avoidance of animal flesh/all animal products; and (2) conscientious omnivorism (CO), the consumption of meat or fish only when it satisfies certain ethical standards. While the former group has recently received much attention in the social science literature, studies specifically examining those who identify themselves as COs have been virtually nonexistent. The present research sought to investigate possible underlying attitudinal differences between the two groups. Results indicated that relative to veg*ns, COs evaluated animals less favorably, meat more favorably, and were lower in idealism, misanthropy, and ingroup identification. Mediation analysis demonstrated that differences between COs and veg*ns in the perceived acceptability of killing animals for food were mediated by beliefs about animals and meat. The discussion largely speculates on the causal direction of these effects.

Efforts to overcome vegetarian-induced dissonance among meat eaters.

Meat eaters face dissonance whether it results from inconsistency ("I eat meat; I don't like to hurt animals"), aversive consequences ("I eat meat; eating meat harms animals"), or threats to self image ("I eat meat; compassionate people don't hurt animals"). The present work proposes that there are a number of strategies that omnivores adopt to reduce this dissonance including avoidance, dissociation, perceived behavioral change, denial of animal pain, denial of animal mind, pro-meat justifications, reducing perceived choice, and actual behavioral change. The presence of vegetarians was speculated to cause meat eating to be a scrutinized behavior, remind meat eaters of their discomfort, and undermine the effectiveness of these strategies. It was therefore hypothesized that exposure to a description of a vegetarian would lead omnivores to embrace dissonance-reducing strategies. Supporting this hypothesis, participants who read a vignette about a vegetarian denied animal mind more than participants who read about a gluten-free individual. It was also hypothesized that omnivores would be sensitive to individual differences between vegetarians and would demonstrate using dissonance-reducing strategies more when the situation failed to provide cognitions consonant with eating meat or to reduce dissonant cognitions. Four experiments supported this prediction and found that authentic vegetarians, vegetarians freely making the decision to abandon meat, consistent vegetarians, and anticipating moral reproach from vegetarians produced greater endorsement of dissonance-reducing strategies than their counterpart conditions.

Differences between health and ethical vegetarians. Strength of conviction, nutrition knowledge, dietary restriction, and duration of adherence.

Little research has been published concerning the differences between health oriented and ethically oriented vegetarians. The present study compared differences in conviction, nutrition knowledge, dietary restriction, and duration of adherence to vegetarianism between the two groups. Subjects completed an online survey and were grouped by original reason for becoming vegetarian (n=292, 58 health, 234 ethical), and current reason for remaining vegetarian (n=281, 49 health, 232 ethical). Whether grouped by current or original motivation, ethical vegetarians scored higher on the conviction instrument than health vegetarians and exhibited somewhat greater dietary restriction (significant when grouped by current motivation) and had been vegetarian for longer (significant when grouped by original motivation). Nutrition knowledge did not differ between the two groups. The results suggest that ethical vegetarians could experience stronger feelings of conviction and consume fewer animal products than health vegetarians, and may remain vegetarian longer. More research is necessary to understand how vegetarians' eating behaviors are influenced by their motivational profiles.

Introdução de alimentos supérfluos no primeiro ano de vida eas repercussões nutricionais / Introduction of junk food in the child’s first year and its nutritional outcome / Introducción de alimentos superfluos en el primer año de vida y las repercusiones nutricionales

O objetivo deste trabalho foi verificar o consumo de alimentos supérfluos por crianças de quatro a doze meses deidade usuárias do serviço público/Sistema Único de Saúde (SUS) na cidade de Frutal/MG. Foram avaliadas 300crianças, que representaram 70,7% da população local, segundo dados da base municipal. O estudo édescritivo, transversal e de abordagem quantitativa. Foram considerados alimentos supérfluos aqueles queapresentam quantidades excessivas de lipídeos e/ou açúcares, ou substâncias indesejáveis para o consumonessa faixa etária, como corantes e conservantes químicos. Avaliou-se o consumo de suco industrializado empó, de salsicha, mortadela, salame, sopas e salgadinhos de pacote, macarrão instantâneo, gelatina, pudim,refrigerantes, pipoca, balas, pirulitos, sorvetes, chocolate, além de iogurte, queijo petit suisse e leite fermentado.Aplicou-se um questionário durante a pesagem mensal das crianças, em todas as oito unidades básicas desaúde. A análise estatística foi descritiva e revelou os alimentos supérfluos mais consumidos entre crianças dequatro a seis meses e de seis a doze meses de idade. Observou-se uma elevada introdução de alimentossupérfluos, sendo que 80,2% das mães e/ou responsáveis relataram oferecer um ou mais destes alimentos àssuas crianças.

This study aimed at assessing the intake of junk food by children aged between four and 12 months, who makeuse of the Sistema Único de Saúde (SUS) (Unified Health System) public service, in the city of Frutal/MG, Brazil.This descriptive, transversal and quantitative approach study monitored 300 children who represented 70.7% ofthe age group population according to the municipal official data. Junk food is here defined as food whichcontains excessive levels of fat and/or sugar or any undesirable substance for this age group, such as artificialcoloring and chemical preservatives. The intake of instant powdered fruit juice, hotdogs, sausages, salami, soupsand salt snacks, instant pasta, Jell-O, pudding, soda, popcorn, candies, lollipops, ice cream, chocolate, yogurt,petit swiss cheese and fermented milk was assessed. A questionnaire was applied during the monthly weighing ofthese children at every one of the eight Basic Health Units. The kind of junk food most consumed by four to sixmonth-old and six to 12 month-old children were identified through statistical, descriptive analysis. A frequentintroduction of junk food was observed in 80.2% of mothers and/or caregivers having admitted feeding theirchildren one or more of the mentioned food products.

El objetivo de este trabajo fue verificar el consumo de alimentos superfluos por niños de cuatro a doce meses deedad, que utilizan el servicio público/Sistema Único de salud (SUS) en la ciudad de Frutal/MG. La evaluación fuehecha con 300 niños, lo que representa un 70,7% de la población local, según datos de la base del municipio. Setrata de un estudio descriptivo, transversal y de abordaje cuantitativo. Fueron considerados como alimentossuperfluos aquellos que presentan cantidades excesivas de lípidos y/o azúcares o sustancias indeseables para elconsumo en esta franja de edad, como colorantes y conservantes químicos. Se evaluó el consumo de jugo enpolvo industrializado, embutidos, sopas, patatas chips, macarrones instantáneos, gelatina, budín, gaseosa,palomitas, caramelos, chupetines, helados y chocolate, así como yogurt, queso petit suisse y leche fermentada.Se aplicó un cuestionario durante el pesaje mensual de los niños, en las ocho Unidades Básicas de Salud. Elanálisis estadístico fue descriptivo y reveló los alimentos superfluos más consumidos entre niños de cuatro a seismeses y de seis a 12 meses de edad. Se observó un alto consumo de este tipo de alimentos y un 80,2% de lasmadres y/o responsables afirmaron ofrecer uno o más de estos alimentos a sus niños.

Reflexões sobre o adoecer e mudanças dietéticas durante a assistência nutricional em pacientes com hepatite C / Reflections about getting sick and dietetic changes during nutritional assistance with hepatitis C patients

Trata-se de investigar os significados atribuídos por pacientes portadores do vírus da hepatite C sobre a doença e o tratamento dietético. Para tanto, adota-se a metodologia da pesquisa qualitativa em que o sujeito interage com sua narrativa sobre o objeto de estudo e os pesquisadores analisam cuidadosamente seus enunciados. As acepções sobre o adoecer e as mudanças dos hábitos alimentares e de vida dos pacientes foram analisadas por meio da obtenção de entrevistas em profundidade. Ao trazer os sentidos expressos sobre a doença, cria-se a possibilidade de compreensão dos aspectos culturais sobre a alimentação, a nutrição e a dietética; um desafio para os profissionais de saúde e nutrição, que precisam relatar a seus pacientes a necessidade de seguir hábitos alimentares mais saudáveis, implicando alterações nem sempre simples de serem realizadas. Consideram-se hábitos e representações do ato da alimentação, como parte da identidade cultural do sujeito. Justifica-se este estudo pela necessidade de situar maior interação entre profissionais, estudantes de saúde e pacientes de modo a ampliar a compreensão dos fenômenos que cercam a experiência da doença pelos pacientes. Conclui-se que os pacientes de hepatite C atendidos no ambulatório do Hospital Universitário da cidade de Salvador e o profissional podem atingir os objetivos de aconselhamentos nutricionais, se trilharem direções dialógicas. Com isso, observou-se a adesão à orientação dietética sem rupturas bruscas e sofrimentos dos pacientes.

This paper investigates the meanings attributed by patients to hepatitis C on disease and dietary treatment. To this end, we adopt the methodology of qualitative research in which the individual interacts with his narrative on the subject of study and the researchers carefully examine their statements. The meanings of the illness and changes in dietary habits and life of the patients were analyzed by obtaining in-depth interviews. By bringing the senses expressed about the disease, it creates the possibility of understanding cultural factors on diet, nutrition and dietetics - a challenge for health professionals and nutrition, which need to report their patients the need to follow dietary healthier, involving changes not always simple to perform. Habits and representations of the act of feeding are considered part of the cultural identity of the subject. This study is justified by the need to place greater interaction among professionals, students, patients and health so as to broaden the understanding of the phenomena that surround the experience of illness by patients. We conclude that outpatients with hepatitis C at the University Hospital in the city of Salvador and the professional can achieve the goals of nutritional advice, if they follow dialogic lines. Thus, there was compliance with dietary counseling without sudden breaks and suffering of patients.

[Personal responsibility for health. An interdisciplinary discussion on obesity as an example]. / Verantwortung für die eigene Gesundheit. Eine interdisziplinäre Diskussion am Beispiel der Adipositas.

Considering obesity as an example, the present study has developed an ethical, legal and psychological understanding of personal responsibility, which aims at enabling and activating health promoting behaviour. Enhancing individual capabilities and modifying social and political factors that have an effect on individual behaviour are highlighted as a promising, appropriate and ethically sound strategy of prevention.