The "to feed or not to feed" dilemma.

Advance directives can promote and improve communication between the patient and the provider and ideally safeguard the resident's interests by directing medical care. Participation on the facility's ethics committee allows the dietitian to become involved in the legal and ethical issues regarding feeding and to promote the use of specific advance directives for nutrition and hydration. Consider the goals of patient care carefully and assure that they are individualized and patient-centered. Continually reassess nutritional status and collaborate with the health care team in recommending interventions and care plans for each case.

Clinical indicators associated with unintentional weight loss and pressure ulcers in elderly residents of nursing facilities.

OBJECTIVE: To monitor adults older than 65 years living in nursing facilities and who experience unintentional weight loss of more than 10% of actual body weight in 6 months or more than 5% in 1 month or who have stage II, III, or IV pressure ulcers. SUBJECTS: We reviewed 290 medical records for unintentional weight loss and 265 for pressure ulcers. DESIGN: Two data-collecting instruments were used: one for pressure ulcers and one for unintentional weight loss. Indicators for each instrument were selected to monitor clinical conditions that tend to be problem-prone areas for these two populations. STATISTICAL ANALYSIS: Descriptive statistics were used to calculate the frequency of each indicator for each population. RESULTS: Of the 24 indicators for unintentional weight loss, the 6 indicators present most often, in descending order, were reduced functional ability, intake of 50% or less of food served for the past 3 consecutive days, chewing problems, serum albumin level less than 35 g/l with normal hydration status, cholesterol level less than 4.1 mmol/L, and refusal of 50% or more of food replacement for the past 7 days. For the residents with pressure ulcers, the indicator present most often was serum albumin level less than 35 g/L with normal hydration status. The three highest intervention indicators were receives 1.2 g protein per kilogram of actual body weight, receives 120 mg or more of vitamin C daily, and receives 1 1/2 times the energy required based on goal body weight. When serum albumin level was documented in the medical record, it was a valid indicator for both diagnoses. CONCLUSIONS: Inappropriate dietary intake, disease, and disability place residents in nursing facilities at risk for malnutrition. Thus, it is important to obtain laboratory values when assessing elderly residents and determining their nutritional status.