To Feed or Not to Feed Ethics and Nutrition Considerations in LTC
Ethical nutrition considerations in today’s long term care environment are increasingly complex. This is for a variety of reasons, many of which impact on the nutrition decisions that need to be made by the health care team, residents, families and powers of attorney in our long term care homes.
Significant financial and human resources are being channeled into home care programs across the country, resulting in a greater emphasis on providing appropriate community services that enable seniors to stay in their own homes longer.
Expansion of Meals on Wheels programs, special transportation programs and respite care all assist seniors to remain safely within their own homes for as long as possible. Ontario’s “Aging at Home Strategy” is just one example of how expansion of services for seniors is assisting in this way. It is only when seniors are no longer safe, or their care needs are too great to manage in their own home, that long term care is required.
Changing care needs
Today’s seniors entering a long term care (LTC) home are generally more frail and require a much greater level of care, including increased intensity of nutrition care, than in past. Due to their malnourished state, increasingly complex co-morbidities and greater need for nutrition interventions, registered dietitians working in LTC today are assessing many more newly admitted residents that they determine to be at high nutrition risk.
Also, lengths of stay have decreased because of residents’ increasing frailty. Individuals are sometimes admitted to a home for only a month before succumbing to their various illnesses.
While best practice would indicate a high number of interventions are required, these are sometimes put in place for a very short time and questions may arise as to the efficacy of this practice.
This current situation in the LTC sector, coupled with ever increasing demands on both human and financial resources, requires inter-professional collaboration and an interdisciplinary approach to some very basic and challenging ethical dilemmas as to how we care for our LTC residents in 2011.
Ethical dilemmas
When we consider ethical considerations in LTC, we often consider the life and death questions; a decision whether to prolong life using artificial means represents a huge ethical challenge. But ethical decisions are also made on a day to day basis.
In the nutrition department, a decision around how often to offer special menu choices to celebrate theme days or whether to buy locally grown food versus imported food represents ethical considerations.
Do we support local producers and pay more money? Do we purchase prepared foods which we know contain more sodium? No matter what decision has to be made, residents’ rights and choice must always be considered. We also must balance the role of the family,
POA or substitute decision maker in the planning of nutrition and hydration care and individual decision making concerning nutrition care.
Family councils and residents councils all have input into the care team’s professional knowledge and best practices regarding home-like and quality dining. Resident and family education should be provided on the risks involved in any decisions, the implementation of interventions by the care team to manage those risks and acceptance by the team of the resident’s right to make those decisions.
When “end of life” decisions are made around foods and fluids, many factors influence what we decide as care givers or how we perceive a family’s decisions.
Cultural and religious beliefs stress the sanctity of preserving human life. We, as care givers, consider what we would do in the same situation if the resident were
Food is generally associated with happy times and family memories. Occasionally, the lack of available food can evoke equally unhappy memories. Whatever our culture and background, we bring very strong feelings around the role that food plays in our lives and the importance of eating and drinking to the maintenance and enjoyment of all life.
When residents stop eating and drinking, we need to determine the causes and whether these causes are reversible and if a cure is possible. A resident who is not eating because of an acute infection may be treated successfully with antibiotics and their appetite will return. A resident with end stage dementia or a chronic disease presents a different challenge.
Forcing residents to take foods and fluids when the outcome (death) is inevitable is neither: successful, respectful of resident’s rights/wishes, nor ethically sound. In fact, many studies have concluded that residents who are slightly dehydrated face a somewhat less distressing death.
As care givers, while we cannot change the dying process we can help loved ones deal with the situation by explaining nutrition and palliative care, providing reassurance that the resident is not suffering or feeling hunger or thirst and by offering suggestions for care (moistening lips, holding hands, or other expressions of care that do not involve the foods or fluids that the resident is refusing). Our ability to make these suggestions is our way of providing care when other offers are no longer appropriate.
Sometimes as care givers we question whether valuable financial and human resources should be spent on an elderly person or whether these resources should be channeled to a younger patient. Should the decision ever be made on the basis of “that person is too old”?
As care givers, we may be able to justify such a decision if we are unrelated to that old person; however, we would come to a totally different conclusion if the old person in question were our mother or grandmother.
The case for enteral feeds in LTC
Initiating an enteral (tube) feeding in a frail elderly person presents its own set of ethical debates. In many cases, while dehydration and malnutrition can be postponed through artificial means of feeding, the elderly resident may not withstand the required medical procedures to allow for an enteral feeding to be carried out.
There are numerous instances where an enteral feeding has been initiated only to have the resident succumb to the stress of the surgical procedure.
While enteral feeds may correct confusion resulting from dehydration and improve nutritional status, and provide emotional support to family that “something is being done,” there are risks.
The resident’s decreased mobility while on a tube feed, combined with the resulting increased risk of skin breakdown and the increased risk of aspiration pneumonia are all factors that must be considered.
Day to day challenges
The day to day decisions required in LTC present their own set of ethical debates. Studies have shown that while most residents have come to terms with their mortality and their decisions around advance directives, the day to day issues and how they are handled are of far greater concern and can significantly affect individual quality of life.
How the care team approaches these issues and handles them is of utmost concern to the resident. The team’s decisions around the use of liberalized diets, when to initiate nutrition supplements and foods being brought in from outside are just three examples of the day to day issues that have an ethical component.
Clothing protectors or aprons (often called bibs which, in itself affects residents’ dignity) are often thread bare and worn. Not having enough protectors for all residents that are in good repair indicates that at some level a decision has been made not to purchase sufficient numbers. While this may be a financial decision, it has ethical considerations as residents are entitled to be treated with dignity while they are eating.
Staff involved with feeding residents (sometimes referred to as “feeders” instead of “residents requiring assistance” – another dignity and respect issue) may choose to mix pureed foods together to speed up the process of feeding their residents. This not only masks the taste of the individual foods but potentiates the risk of choking if residents are fed too quickly.
While the decision around staffing may be considered a financial one, there are also ethical considerations as to what is best practice concerning “eating with dignity.”
A home’s commitment to “Pleasurable Dining” with frequent audits and improvements indicates their ethical decision that this is an important component in their care delivery.
Ethical decision making
Many homes now have functioning ethics committees and use an inter-professional approach to deal with complex ethical dilemmas. Many homes also have the services of a bioethicist to assist with decision making.
Education of staff at all levels remains critical so that everyone feels supported with whatever decisions are being made whether they are those of a life and death nature or day to day.
The following scenarios illustrate some ethical dilemmas and can actually provide a starting point for discussions at team meetings: • Ms. H has lived in the LTC Home for 6 months. She has gained 40 pounds in this time and is at risk for health complications because of her weight. Although she is on a reducing diet, staff reports that her daughter is often bringing her “treats.” The dietitian has met Ms. H and her daughter but they say Ms. H is following her diet with only the occasional extras. • Mr. C has difficulty with swallowing. A pureed texture diet, with thickened fluids, has been recommended for reasons of safety. Mr. C had been seen eating chips and drinking pop in his room. The staff is concerned that he may choke. • Mr. M needs a strict diet to help manage his kidney disease. The doctors are very concerned because he is not following his diet and his kidney function is failing quickly. The Dietitian is not confident that Mr. M understands the implications of not following his diet. These are all common occurrences in the LTC setting and all readers will identify with residents in their homes. Other examples of actions or decision making may have a less obvious ethical component.
In summary
Ethical decisions are made every day as we go about doing our various duties and everyone working in LTC has a role to play. Ethical decisions challenge our beliefs and we must talk with the care team, as well as the residents involved, their families and POAs and respect everyone’s point of view. There are definitive rules when we are making ethical decisions – however, resident safety, resident dignity, legislation, and professional responsibility (dietitians are required to protect a clients right to autonomy, respect and dignity) all determine how we come up with solutions to the many challenges that we are all dealing with as we deliver care to our long term care residents in 2011.