Use Of Artificial Nutrition Research Articles

Impact of fee-revision policy for gastrostomy on its implementation among older adults with dementia in Japan

ObjectivesThis study aimed to evaluate the impact of the policy to reduce the reimbursement fee for percutaneous endoscopic gastrostomy (PEG) on the number of PEG procedures performed among older adults with dementia. Study designInterrupted time series (ITS). MethodsWe used the monthly aggregated data of the number of PEG procedures in older adults with dementia (both broad and narrow definitions), between 2012 and 2018, from the claims data in Fukuoka Prefecture, Japan. A single ITS design was used to estimate changes in the outcome following each intervention (i.e., first, second, and third interventions performed in 2014, 2015, and 2016, respectively). A controlled ITS design was applied to estimate the effects after the sequence of interventions (pre-intervention: 2012–2014; post-intervention: 2016–2018). The control group comprised patients with malignant head and neck tumors who underwent PEG procedures outside the scope of this policy restriction. ResultsThe number of PEG procedures decreased significantly only in the month wherein the third intervention was introduced (broad definition: IRR = 0.11, CI = 0.03–0.49; narrow definition: IRR = 0.15, CI = 0.03–0.75). No significant difference was observed between the treatment and control groups during the post-intervention phase. ConclusionsThe impact of fee-revision policy for PEG on the decrease in PEG procedures among older adults with dementia is remarkably minimal. It is difficult to reduce unnecessary PEG procedures by relying on this financial incentive alone. Policy decision-makers should consider methods to prevent inappropriate use of artificial nutrition for older adults at their end-of-life stage by reforming the health delivery system.

Nutritional education and counseling program for adult cancer patients during radiotherapy: a cluster-randomized clinical trial.

Nutrition education andcounseling is the first-line approach in nutritional support for adult cancer patients; however, it is not well implemented in many clinical settings. This study aims to determine the effect of an evidence-based nutrition education and counseling (NEC) program on nutrition status among cancer patients receiving radiotherapy. This cluster-randomized clinical trial enrolled cancer patients receiving radiotherapy from ten radiotherapy units in three hospitals. Randomization was conducted at the unit level (five units into the NEC group and five units into the usual care group). The primary outcome was nutrition status after radiotherapy measured by the Patient-Generated Subjective Global Assessment (PG-SGA). Secondary outcomes included nutrition-related blood biomarkers after radiotherapy and the use of artificial nutrition and treatment interruption during radiotherapy. A total of 468 patients were enrolled (241 in the NEC and 227 in the usual care group); 196 patients were female with a mean age (SD) of 59.8 (11.9). No difference was found between the NEC and usual care groups in nutrition status and blood biomarkers at baseline. After radiotherapy, patients in the NEC group had lower PG-SGA scores (5.6 vs 6.9; MD = -1.3, p < 0.001) and lower malnutrition rate (56.0% vs 70.5%; OR = 0.5; p = 0.004) compared with the usual care group. The usages of artificial nutrition and treatment interruption during radiotherapy and the level of blood biomarkers after radiotherapy did not differ between groups. Nutrition education and counseling is an effective approach in reducing malnutrition and can be generalized to multiple radiotherapy settings. REGISTERED UNDER CLINICALTRAILS. None.

The impact of the introduction of a clinical nutrition unit in a hospital: a retrospective observational study.

Objectives: the study describes the evolution over the years of the use of artificial nutrition, in particular after the introduction of a dedicated Clinical Nutrition and Dietetic Service. Methods: a single-center, retrospective observational study performed with data collected from 2014 to 2019 at the Regional Hospital of Locarno, Switzerland. Results: from 2014 to 2019, there has been an increase in the number of patients identified as being at risk of malnutrition. We observed a reduction in the use of parenteral nutrition in all services, especially after the introduction of the dedicated Clinical Nutrition and Dietetic Service. There would seem to be a switch from enteral to oral nutrition with increased use of oral nutritional supplements. Conclusions: the introduction of a dedicated Clinical Nutrition and Dietetic Service in the care of patients with nutritional issues would seem to reduce the use of artificial invasive nutrition, despite an increase in the number of patients identified as being at risk of malnutrition.

Формула энтерального питания у больных с тяжелым острым панкреатитом

Несмотря на отсутствие специальной терапии больных острым панкреатитом, последние достижения, которые используют неспецифические ранние методы лечения, привели к улучшению результатов. Эти результаты получены из исследований по применению регидратации, аналгезии, профилактических антибиотиков и ограничения эндоскопической ретроградной холангиопанкреатографии у пациентов с сопутствующим острым холангитом. Однако самое заметное и последовательное улучшение результатов пациентов за последнее десятилетие было отмечено в исследованиях, изучавших использование искусственного питания, как энтерального, так и парентерального, у больных острым панкреатитом. Имеющиеся данные, учитывая современное состояние патофизиологии острого панкреатита, подчеркивают, что пищевая поддержка с соответствующими питательными добавками является ключевым элементом для ограничения местного воспаления и предотвращения или лечения панкреатит-ассоциированных осложнений. Данный обзор литературы, полученной из базы Pubmed, сосредотачивается на последних достижениях по оптимальной стратегии энтерального питания у больных с тяжелым острым панкреатитом, а также роли пищевых добавок, таких как пробиотики, пребиотики, синбиотики, глутамин, аргинин, омега-3 жирные кислоты и витамины, для оценки улучшения результатов лечения этих пациентов и перспективы дальнейших исследований.

Beneficial Effect of Immune-Enhanced Enteral Nutrition on Immune Function in Patients With Severe Neurological Diseases: A Single-Center Randomized Controlled Trial

Background: Undernutrition is the main reason for the use of artificial nutrition in patients with severe neurological diseases. However, the clinical and immunological outcomes of enteral nutrition supplemented with immunomodulatory nutrients in these patients remain unclear.Methods: In this single-center, randomized controlled study, 57 patients with severe neurological diseases were randomly divided into the following two groups according to the type of enteral nutrition they would receive: immune-enhancing (IE) (n = 27) and non-IE (NIE) (n = 30). The IE and NIE groups received enteral nutrition supplemented with immunomodulatory nutrients and standard enteral nutrition, respectively. We compared the nutritional status and the state of cellular immunity between the patients of the two groups. Clinical and immunological variables were evaluated following nutritional treatment.Results: Feeding intolerance was lower in the IE than that in the NIE group (P = 0.04). However, there were no significant differences between the results of the two groups in terms of length of stay in the intensive care unit or hospital, extubation time, or body mass index (P > 0.05). The CD4+ T-lymphocyte count and CD4+/CD8+ ratio in the peripheral blood increased significantly in the IE group. The expression of CD28 activated cell surface markers was higher in the IE than in the NIE group. In addition, increased plasma interferon-γ levels were recorded in the IE group, whereas the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-8, and IL-10 decreased.Conclusions: Immune-enhanced enteral nutrition could improve the immune status and feeding tolerance in patients with severe neurological diseases.Trial Registration:www.chictr.org.cn/index.aspx, identifier: ChiCTR-IPR-17013909.

How to choose the best route of feeding during critical illness

Increased and specific nutritional requirements occurring during critical illness need to be covered by appropriate administration of energy, nitrogen and micronutrients, especially in case of pre-existing malnutrition, chronic insufficient oral intakes or expected delay before recovery of eating. The use of artificial nutrition (enteral or parenteral) is recommended whenever the oral intakes are insufficient, in order to avoid the detrimental consequences of malnutrition and promote the best possible outcome of severely ill patients. This paper aims to provide an overview and practical recommendations of artificial nutrition therapy in the ICU setting.

Use of artificial nutrition near the end of life: Results from a French national population-based study of hospitalized cancer patients.

BackgroundThe use of artificial nutrition, defined as a medical treatment that allows a non‐oral mechanical feeding, for cancer patients with limited life expectancy is deemed nonbeneficial. High‐quality evidence about the use of artificial nutrition near the end of life is lacking. This study aimed (a) to quantify the use of artificial nutrition near the end‐of‐life, and (b) to identify the factors associated with the use of artificial nutrition.MethodsThis was a retrospective cohort study of decedents based on data from the French national hospital database. The study population included adult cancer patients who died in hospitals in France between 2013 and 2016 and defined to be in a palliative condition. Use of artificial nutrition during the last 7 days before death was the primary endpoint.ResultsA total of 398 822 patients were included. The median duration of the last hospital stay was 10 (interquartile range, 4‐21) days. The artificial nutrition was used for 11 723 (2.9%) during the last 7 days before death. Being a man, younger, having digestive cancers, metastasis, comorbidities, malnutrition, absence of dementia, and palliative care use were the main factors associated to the use of artificial nutrition.ConclusionThis study indicates that the use of artificial nutrition near the end of life is in keeping with current clinical guidelines. The identification of factors associated with the use of artificial nutrition, such as cancer localization, presence of comorbidities or specific symptoms, may help to better manage its use.

A communication strategy using a video support tool and structured family meetings for relatives of patients dying in the ICU.

81 Background: Death in the ICU is an extraordinarily stressful event. Qualitative and quantitative studies have identified effective communication between caregivers and families to be important throughout the decision making process. In many ICUs, the end-of-life family conference is an opportunity to ask questions, express concerns, and confront painful emotions with the help of compassionate professionals. Methods: A prospective study in a single ICU center. The ICU physician, palliative care team, and research nurse interviewed surrogate decision makers. The only criterion for inclusion in the study was anticipated death in one year. Patients younger than 18 were excluded from the study, as were those unable to speak English. Prior to the family meeting, families were offered an opportunity to watch a video on EOL decision-making made by the research team. The meeting itself followed a script, guided by four steps:establish diagnosis, share prognosis, elicit goals of care, recommend treatment. The investigators recorded ICU and patient characteristics on standardized forms. Results: 22 families were included. A decision to forego life-sustaining treatment and transition to comfort care or hospice was pursued by 77% of families. There were few non-beneficial interventions, such as CRRT or use of artificial nutrition; withdrawal of mechanical ventilation and vasopressors was common. Qualitative commentary suggested that time spent by providers were sufficient and the video support tool was clear and easy to understand. Conclusions: EOL family conferences improve communication between ICU staff and family members and assist families in decision making, especially for cancer syndromes. The structured family meetings offered opportunities to discuss patient’s wishes, alleviate feelings of guilt, and understand the goals of care. Patients received few non-beneficial treatments and families were likely to accept realistic goals of care. This highlights the potential role for video-support tools in advance care planning. Future studies reporting overall LOS and bereavement data are important quality markers and pending in a future report.

Nutrition at the End of Life: It’s Not What You Say, It’s How You Say It

The purpose of this review is to describe and appraise the available scientific evidence to guide the use of artificial nutrition and hydration at the end of life, with a focus on communicating with patients and families who are facing these decisions. Research suggests artificial nutrition and hydration (ANH) may be burdensome at the end of life, yet disparities for its use in clinical practice persist. While no clear evidence supports the use of ANH for the majority of terminally ill patients, emerging data suggests that a subset of patients may derive some benefit. No clear criteria exist to ascertain the beginning of the dying phase, which can present challenges surrounding ANH. A better understanding of symptom burden and thoughtful communication between the clinician and patient can facilitate development of a medical plan of care, with or without ANH, that best meets the patient’s goals of care.

Discrepancies in the use of chemotherapy and artificial nutrition near the end of life for hospitalised patients with metastatic gastric or oesophageal cancer. A countrywide, register-based study

AimTo evaluate the frequency and the factors associated with the use of chemotherapy and artificial nutrition near the end of life in hospitalised patients with metastatic oesophageal or gastric cancer. MethodsNationwide, register-based study, including all hospitalised adults (≥20 years) who died with metastatic oesophageal or gastric cancer between 2010 and 2013, in France. Chemotherapy and artificial nutrition during the final weeks of life were considered as primary outcomes. ResultsA total of 4031 patients with oesophageal cancer and 10,423 patients with gastric cancer were included. While the proportion of patients receiving chemotherapy decreased from 35.9% during the 3rd month before death to 7.9% in the final week (p < 0.001 for trend), the use of artificial nutrition rose from 9.6% to 16.0% of patients. During the last week before death, patients with stomach cancer were more likely to receive chemotherapy (adjusted odds ratio (aOR) = 1.35, 95% CI = 1.17–1.56) but less likely to receive artificial nutrition (aOR = 0.80, 95%CI = 0.73–0.88) than patients with cancer of the oesophagus. The adjusted rates of chemotherapy use during the last week of life varied from 1.6% in rural hospitals to 11.2% in comprehensive cancer centres, while the adjusted probability to receive artificial nutrition varied from 12.1% in private for-profit clinics up to 19.9% in rehabilitation care facilities (p < 0.001). ConclusionsOur study shows that in hospitalised patients with metastatic oesophageal or gastric cancer, the use of chemotherapy decreases while the use of artificial nutrition increases as death approaches. This raises important questions, as clinical guidelines clearly recommend to limit the use of artificial nutrition in contexts of limited life expectancy.

Artificial Nutrition and Hydration in People With Late-Stage Dementia.

The progressive nature of dementia marks this disease as a terminal illness in the advanced stage, and palliative care rather than curative treatment is indicated. The use of feeding tubes to deliver artificial nutrition and hydration at end of life is often part of the plan of care for people with dementia. Current evidence, however, suggests that tube feeding in advanced dementia is not beneficial and the burdens of the procedure and the feedings themselves outweigh any benefits. Evidence also reveals that healthcare providers may lack evidence-based knowledge about artificial nutrition and hydration to adequately inform families and surrogate decision makers. This article examines the evidence regarding use of artificial nutrition and hydration for patients with end-stage dementia and offers implications for home care clinicians.

P119 The Use of Artificial Nutrition and Hydration in an Inpatient Hospice in Singapore

P119 The Use of Artificial Nutrition and Hydration in an Inpatient Hospice in Singapore

1307P - Use of treatments of questionable benefit in hospitalized patients with metastatic gastric or esophageal cancer near the end of life. A country-wide, register-based study

The benefit of life-prolonging treatments in terminally ill cancer patients is debated. Little is know, however, about the aggressiveness of care in patients with metastatic esophagus or stomach cancer. Register-based study in France, including all hospitalized adults (≥20 years) who died as the result of metastatic esophageal or gastric cancer between 2010 and 2013. The receipt of chemotherapy and the use of artificial nutrition during the last 3 months of life were defined as primary outcomes. 4,031 patients with metastatic esophageal cancer and 10,423 patients with metastatic gastric cancer were included (n total= 14,454). Overall, 47.6% of patients received chemotherapy in their last 3 months of life, with a significant decrease over time (from 35.9% during the third month before death to 7.9% in the final week of life). In contrast, the receipt of artificial nutrition rose from 9.4% to 16% over the same period of time. This increase in the use of artificial nutrition was observed for both esophagus and stomach cancer, across all age-groups, and regardless of the number of chronic comorbidities (p > 0.001 for trend). During the last week before death, the likelihood of receiving artificial nutrition decreased with age (adjusted OR= 0.80, 95%CI= 0.77-0.84 for each 10-year increase in age), and was significantly higher for patients with esophageal cancer compared with gastric cancer (adjusted OR= 1.25, 95%CI= 1.13-1.37). In addition, 3.5% of patients received invasive ventilation during the last month before death (5% of patients with esophageal cancer and 3% of patients with gastric cancer, p < 0.001). 6% of patients eventually died in Intensive Care Units, and only 12.6% died in Palliative Care Units. Our study shows that hospitalized patients with metastatic esophageal or gastric cancer are likely to receive treatments of questionable benefit near the end of life. Interventional studies focusing on patient reported outcomes are needed to assess the clinical benefit of artificial nutrition for patients with terminal cancer.

ESPEN guideline on ethical aspects of artificial nutrition and hydration

The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Managing malnutrition in patients with dementia.

As dementia progresses, an individual may experience increasing difficulties in eating and drinking safely. Evidence suggests that admission to hospital may exacerbate these problems. This article aims to familiarise readers with some of the issues associated with providing good nutritional care for a patient with dementia in hospital. Strategies to address the maintenance of oral intake are suggested. The article also explores the use of artificial nutrition in dementia, with examples to clarify when its use may be helpful.

State of food and nutritional care in public hospitals of Ecuador

The ELAN Ecuadorian Study of Hospital Malnutrition returned a malnutrition rate of 37.1% in public hospitals of Ecuador [Gallegos Espinosa S, Nicolalde Cifuentes M, Santana Porbén S; para el Grupo Ecuatoriano de Estudio de la Desnutrición Hospitalaria. State of malnutrition in hospitals of Ecuador. Nutr Hosp (España) 2014;30:425-35]. Hospital malnutrition could be the result of institutional cultural practices affecting the patient's nutritional status. To present the current state of food and nutritional care provided to patients assisted in public hospitals of Ecuador. The state of food and nutritional care provided to 5,355 patients assisted in 36 hospitals of 23 provinces of the country was documented by means of the Hospital Nutrition Survey (HNS), conducted as part of the ELAN Study. HNS recorded the completion of nutritional assessment exercises, the use of food-bymouth, fasting, use of oral nutritional supplements, and implementation and conduction of Artificial nutritional schemes (Enteral/Parenteral); respectively. Less than 0.1% of clinical charts had a diagnosis of malnutrition included in the list of the patient's health problems. Less than half of the patients had been measured and weighted on admission. Serum Albumin values and Total Lymphocytes Counts were annotated on admission in only 13.5% and 59.2% of the instances, respectively. Current weight value was registered in only 59.4% of the patients with length of stay ³ 15 days. An oral nutritional supplement was prescribed in just 3.5% of non-malnourished patients in which significant metabolic stress and/or reduced food intakes concurred. Although up to 10 different indications for use of Artificial nutrition were identified in the sample study, any of these techniques was administered to just 2.5% (median of observed percentages; range: 1.3 - 11.9%) of surveyed patients. Currently, nutritional status of hospitalized patient is not included within therapeutic goals, nutritional assessment exercises are incomplete, and Artificial nutrition is not considered a therapeutic option. From these findings it can only be concluded that the nutritionist still has no place within medical care teams. Adoption of required measures in order to introduce "Food and Nutrition Good Practices" into the medical care in public hospitals of Ecuador is urgently needed.

Food, Identity, and Memory Among Aging Veterans at End of Life

Food is significant from an anthropological and sociological perspective. The emotional and symbolic meanings of food, however, are rarely examined in the health care literature, nor are such meanings specifically linked to end-of-life treatments. The aim of this study was to explore the meaning, value, beliefs, and emotions connected with food and how a cultural model for older adults shapes this meaning related to end-of-life treatments. This article describes a qualitative study of older male veterans with terminal or advanced progressive illness perceptions and beliefs about food. Analysis of the data revealed a cultural model of community identity and social memory as described through food. The meaning of food was highly symbolic and temporal in nature. Given the historical struggle concerning the use of artificial nutrition at end of life, results of this study might provide a foundation upon which clinicians can explore the meaning of food in those with terminal or advanced progressive illnesses and incorporate this into end-of-life decision making. Further clinicians may address the need for nurturance and caring without the use of end-of-life treatments by focusing on physical comfort measures and the use of other nurturing activities to replace the “food connection” between the older adult and family.

Alimentar a vida ou sustentar a morte? Uma reflexão em equipa partindo de um caso clínico

The use of artificial nutrition and hydration in patients in the late stages of dementia is controversial. The prevalence of dementia will continue to increase with the aging population so this topic will become increasingly important. In the more advanced stages of dementia, patients typically are unable to walk or feed themselves, becoming incontinent and aphasic. When confronted with a patient with terminal dementia and dysphagia, the authors searched the literature for the best approach to nutrition for the patient. The decision to insert a nasogastric tube or a percutaneous endoscopic gastrostomy (PEG) for elderly patients with advanced dementia is one of the hardest decisions for health professionals and relatives. The studies reviewed have failed to show that artificial feeding is advantageous in the terminal stage of the disease. They concluded that feeding tube placement in these patients is not helpful for the prevention of pressure ulcers, malnutrition, or for prolonging survival. This procedure may reduce quality of life because of the change in feeding routines. It may require immobilization or sedation of the patient to prevent them from removing the tube. Family members should be more informed to make better decisions to improve the quality of life in the last days of the patient. Further studies are needed so that the risks and benefits of tube feeding are clarified as well as the advantages and disadvantages of each method.

Artificial nutrition in old patients dying of dementia.

The aim of the review is to show main and recent evidence on and tendencies about artificial nutrition in advanced dementia. Several studies in the last decade had been performed to provide evidence that supports lack of benefits or improvements in many aspects about caring of the elderly with advanced dementia. In spite of the evidence, we find an increased number of patients still submitted to artificial nutrition. There is high prevalence of misperceptions and misbeliefs about artificial nutrition among healthcare professionals in this scenario. Hand feeding for these patients is offered as an alternative arrangement, which may be characterized as dilemma. The decision-making process in artificial nutrition is considered as a difficult, complex and distressful issue, which addresses new strategies for improvement. Despite the lack of evidence of benefits, the use of artificial nutrition remains commonplace in advanced dementia. Patient's wishes and family values should be taken into account in the decision-making process, as well as legal and ethical issues. Communication skills and acknowledgment of recent evidence are essential in decision-making in order to achieve the patient's best interests. Educational strategies and randomized prospective studies concerned about dying patients with advanced dementia are required.

PP083-SUN CT DERIVED MEASURES OF MUSCLE MASS ARE ASSOCIATED WITH FUNCTIONAL ABILITY BUT NOT STRENGTH AND POWER IN PATIENTS WITH UPPER GI CANCER

(81% vs. 69%), they underestimated artificial nutrition use. Dietary counselling was prescribed by physicians in 35% of cases while only 29% of the pts declared to have received it (p < 0.05). Physicians underestimated the lack of nutritional follow-up and impact of nutritional status on fatigue. Conclusion: Our study is the first one crossing visions of patients, relatives and physicians about malnutrition in oncology. There are major differences between patients and doctors on nutritional status and nutritional support. These differences can be explained by a lack of patient’s information, physicians ignorance and lack of specialized teams. Patients could help us to improve nutritional management.