ASPEN international survey on ethical competencies dealing with decision-making in the use of artificially administered nutrition and hydration and competency application in clinical practice.

BACKGROUND: Ethical competencies dealing with decision-making for clinicians involved in artificially administered nutrition and hydration (AANH) have not been defined in the literature. Although clinical assessments identify nutrition needs and appropriate routes of nutrition administration, an assessment of the ethical, cultural, and spiritual implications of the medical nutrition therapy may be overlooked. METHODS: Eleven competency statements were developed by members of two international sections of the American Society for Parenteral and Enteral Nutrition. This descriptive cross-sectional survey study was conducted to measure the importance of the competency statements to the membership of two sections using a five-point Likert scale of 1-5 (1-low to 5-high). RESULTS: A total of 113 responses (12.5% response rate) were obtained predominantly from physicians and dietitians from 25 countries. There was a wide range of world regions of the 49% respondents outside of the United States. Means and SDs were calculated for agreement with the 11 competency statements with overall means ranging from 4.32 to 4.67. Most of the participants cared for adult/older adult patients (63.7%) exclusively, and 12.4% cared for pediatric/neonate patients exclusively; the remainder (23.9%) cared for both populations. Respondents reported they were either experienced, competent, or expert (88.6%) in dealing with ethical issues related to AANH. CONCLUSION: This international interdisciplinary group agreed that the integration of ethical, cultural, and spiritual competencies into clinical decision-making regarding artificially AANH is important.

Nutrition support teams: Institution, evolution, and innovation.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

Ethical Framework for Nutrition Support Resource Allocation During Shortages: Lessons From COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has impacted all aspects of our population. The "Troubling Trichotomy" of what can be done technologically, what should be done ethically, and what must be done legally is a reality during these unusual circumstances. Recent ethical considerations regarding allocation of scarce resources, such as mechanical ventilators, have been proposed. These can apply to other disciplines such as nutrition support, although decisions regarding nutrition support have a diminished potential for devastating outcomes. The principal values and goals leading to an ethical framework for a uniform, fair, and objective approach are reviewed in this article, with a focus on nutrition support. Some historical aspects of shortages in nutrition supplies and products during normal circumstances, as well as others during national crises, are outlined. The development and implementation of protocols using a scoring system seems best addressed by multidisciplinary ethics and triage committees with synergistic but disparate functions. Triage committees should alleviate the burdens of unilateral decisions by the healthcare team caring for patients. The treating team should make every attempt to have patients and the public at large update or execute/develop advance directives. Legal considerations, as the third component of the Troubling Trichotomy, are of some concern when rationing care. The likelihood that criminal or civil charges could be brought against individual healthcare professionals or institutions can be minimized, if fair protocols are uniformly applied and deliberations well documented.

Role of the Nutrition Support Clinician on a Hospital Bioethics Committee.

Hospital bioethics committees comprise a diverse group of healthcare professionals to deal with ethical issues within the institution that arise during patient care. The nutrition support clinicians (NSCs) have an important role on a bioethics committee because of their knowledge and expertise of different nutrition routes and the benefits vs burdens and risks of these modalities, both enteral and parenteral nutrition. Ethics expertise is built on an understanding of ethical principles, when applied in clinical ethics, using critical thinking to prevent ethical dilemmas and to assist in healthcare decision making with a focus on patient-centered care. The NSCs have the opportunity to address ethics during direct patient care with their participation in the intensive care unit interprofessional rounds, family meetings, and surrogate meetings. Evident in ethical dilemmas is often the lack of advance care planning by patients and their family members concerning healthcare wishes for when the individual is unable to communicate their preferences for life-sustaining therapies, including nutrition support. NSCs, as hospital bioethics committee members, are able to support the initiative of National Healthcare Decisions Day to help educate other healthcare clinicians and the public about the importance of advance care planning with communication of healthcare wishes and completion of an advance directive. Components addressed in the article are incorporated into a comprehensive ethics case study, highlighting the role of NSCs.

Practice audit of nutrition support certification.

The National Board of Nutrition Support Certification (NBNSC) is an independent credentialing board responsible for administering certification programs in nutrition support. The NBNSC conducted a study (practice audit) of Nutrition Support Professionals (NSP), with the purposes of defining the role of the nutrition support professional and determining the current elements (knowledge or functions) required for competent NSP practice. This article describes the development of the study, results of the study, and use of the information for future certification in nutrition support. A list of the elements required for competent practice was gleaned from a variety of sources. A rating scale was developed to measure the importance of elements required for competent practice and frequency of practice. From this, an online survey instrument was prepared. Surveys were sent to 5964 NSPs; a total of 891 surveys were completed (return rate of 16.8%). There was 98% agreement among the disciplines of the perceived importance of the elements required of competent entry-level NSP practice; that the survey either completely or adequately described these elements; and that it reflected practice by region as well as among various disciplines and work settings. The results of the practice audit demonstrate a common core of practice (95%) across the nutrition support disciplines as well as a universal core of elements believed to be important for competent nutrition support practice. As a result, the NBNSC has developed 1 examination for future nutrition support certification testing and will confer 1 credential, Certified Nutrition Support Clinician (CNSC), to those who pass the exam.

Enteral Nutrition and Dementia Integrating Ethics.

This narrative review highlights topics related to feeding patients with dementia, including the use of ethical principles and legal precedents; specifies guidelines and practice recommendations; provides an option to assist in applying the recommendations, such as comfort feedings instead of enteral nutrition; promotes the use of early advance care planning to achieve medical therapies based on an individual's wishes; and provides 3 case studies to demonstrate the clinical application of the information presented in the article. Enteral nutrition guidelines and recommendations have been developed by the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics for individuals with dementia. Predominately these guidelines and recommendations focus on patients with advanced dementia due to the dysphagia and progressive disease process. Despite the research and recommendations to forgo enteral nutrition in advanced dementia, the practice continues. The detailed case studies, integrating an interprofessional approach, provide tools for clinicians to incorporate ethical principles and address the communication aspect when dealing with families and surrogate decision-makers for individuals with advanced dementia.

Malnutrition in chronic obstructive pulmonary disease.

Malnutrition in patients with COPD is associated with an impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rate when compared with adequately nourished individuals with COPD. Deterioration in patients with COPD may be the result of malnutrition. In addition, malnutrition could be a sign of other factors directly altered by the disease.

Incorporating Palliative Care Concepts Into Nutrition Practice: Across the Age Spectrum.

A practice gap exists between published guidelines and recommendations and actual clinical practice with life-sustaining treatments not always being based on the patient's wishes, including the provision of nutrition support therapies. Closing this gap requires an interdisciplinary approach that can be enhanced by incorporating basic palliative care concepts into nutrition support practice. In the fast-paced process of providing timely and effective medical treatments, communication often suffers and decision making is not always reflective of the patient's quality-of-life goals. The current healthcare clinical ethics model does not yet include optimum use of advance directives and early communication between patients and family members and their healthcare providers about treatment choices, including nutrition support. A collaborative, proactive, integrated process in all healthcare facilities and across levels of care and age groups, together with measurable sustained outcomes, shared best practices, and preventive ethics, will be needed to change the culture of care. Implementation of a better process, including basic palliative care concepts, requires improved communication skills by healthcare professionals. Formalized palliative care consults are warranted early in complex cases. An education technique, as presented in this article, of how clinicians can engage in critical and crucial conversations early with patients and family members, by incorporating the patient's values and cultural and religious diversity in easily understood language, is identified as an innovative tool.

History and evolution of a successful certification program in nutrition support: the CNSD experience.

As early as the 1970s, articles were published on the role of dietitians in nutrition support. Both the American Society for Parenteral and Enteral Nutrition and The American Dietetic Association addressed the issues of specialization and certification. Development of a specialty area credential requires a strong demand by practicing clinicians, a unique area of clinical practice with a distinct body of knowledge and the commitment to evolve with clinical practice. Numerous dietitians were involved in the inception, development, and leadership that brought forth certification in nutrition support. This article documents the efforts and participation of a dedicated group of professionals whose common goals resulted in the establishment of a successful, sustaining certification in a specialty area of clinical dietetics: certified nutrition support dietitian. The certified nutrition support dietitian program is now in its 15th year with 2,000 dietitians currently certified both nationally and internationally. A primary focus of the credential is to recognize minimum competency for dietitians practicing in the field of enteral and parenteral nutrition and to provide safe and effective nutrition support therapy. This article provides a framework for persons in other specialty areas attempting to develop certification programs.

Gastrostomy tube placement in patients with advanced dementia or near end of life.

Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.

Integrating patient-centered care and clinical ethics into nutrition practice.

The purpose of this article is to present the application of patient-centered care and clinical ethics into nutrition practice, illustrate the process in a case study, and promote change in the current healthcare clinical ethics model. Nutrition support clinicians have an opportunity to add another dimension to their practice with the incorporation of patient-centered care and clinical ethics. This represents a culture change for healthcare professionals, including nutrition support clinicians, patients and their family. All of these individuals are stakeholders in the process and have the ability to modify the current healthcare system to improve communication and facilitate a change by humanizing nutrition support practice. Nutrition support is a medical, life-sustaining treatment, and the use of this therapy requires knowledge by the nutrition support clinician of patient-centered care concepts, preventive clinical ethics, religion/spirituality and cultural diversity, palliative care team role, and advance care planning. Integrating these into the practice of nutrition support is an innovative approach and results in new knowledge that requires a change in the culture of care and engagement and empowerment of the patient and their family in the process. This is more than a healthcare issue; it involves a social/family conversation movement that will be enhanced by the nutrition support clinician's participation.

Practice paper of the Academy of Nutrition and Dietetics abstract: ethical and legal issues of feeding and hydration.

It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians should work collaboratively as part of an interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. This practice paper provides a proactive, integrated, systematic process to implement the Academy's position. The position and practice papers should be used together to address the history and supporting information of ethical and legal issues of feeding and hydration identified by the Academy. Elements of collaborative ethical deliberation are provided for pediatrics and adults and in different conditions. The process of ethical deliberation is presented with the roles and responsibilities of the registered dietitian and the dietetic technician, registered. Understanding the importance and applying concepts dealing with cultural values and religious diversity is necessary to integrate clinical ethics into nutrition care. Incorporating screening for quality-of-life goals is essential before implementing the Nutrition Care Process and improving health literacy with individual interactions. Developing institution-specific policies and procedures is necessary to accelerate the practice change with artificial nutrition, clinical ethics, and quality improvement projects to determine best practice. This paper supports the "Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published in the June 2013 issue of the Journal of the Academy of Nutrition and Dietetics.