ABSTRACT
Background: Enteral tube feeding (ETF), either continuous or non-continuous may be used to meet nutritional needs but is associated with risks of aspiration pneumonia, delayed gastric emptying or diarrhoea. These can have serious consequences, particularly for patients who are critically ill or with swallowing disorders [1]. The aim of this review was to compare the incidence of complications associated with non-continuous (N-CETF) versus continuous delivery (CETF). Method: Databases MEDLINE, CINAHL, Cochrane Library, ProQuest, AMED and SCOPUS were searched between February 26th - March 8th 2013. Both the search and review were carried out by a single investigator. All study designs were considered that assist in answering the question. Outcome measures were aspiration pneumonia (AP), pulmonary aspiration, delayed gastric emptying and diarrhoea. Quality assessment was carried out on all included studies using a tool for quantitative studies [2]. Results: 7 studies were included: 4 randomized controlled trials (RCTs); 2 controlled clinical trials (CCTs); and 1 case study (total of 682 subjects). All trials commenced in hospital, 4 in general medical wards and 3 in intensive care. Of the 5 studies with AP as an outcome, none reported a significant difference between N-CETF and CETF. Of the 3 studies reporting the incidence of stool frequency and consistency 2 found no significant difference between N-CETF and CETF. However, 1 CCT reported a five-fold increased risk of diarrhoea with fibre-free N-CETF when compared to fibre-rich CETF. There was no statistically significant difference between the two modes of feeding with regard to delayed gastric emptying and pulmonary aspiration. Of the 4 RCTs 3 were rated to be of moderate quality and the remaining 4 studies were rated to be of weak quality. Discussion: No strong evidence exists of clear benefit for one mode of delivery over another, which is consistent with previous review literature [3] and guidelines [4]. The lack of clear, good-quality evidence in ETF studies may in part be due to ethical considerations. The absence of an internationally standardized tool for assessing stool consistency and frequency undermines the validity and reliability of some of the stated results (incidence of diarrhoea). Conclusion: This review does not provide conclusive evidence that the incidences of complications are different between N-CETF and CETF and is thus unable to make recommendations for a change in practice.
ABSTRACT
Background: Decisions about artificial nutrition and hydration (ANH) can be difficult to make. Team working, good communication and listening to other team views are recommended in non-emergency decisions relating to ANH (Royal College of Physicians and British Society of Gastroenterology [1]. The experience of dietitians’ involvement in these decisions has not been investigated. This research aims to explore the lived experience of dietitians’ involvement in decisions related to ANH. Methods: 16 registered dietitians were interviewed as part of a qualitative phenomenological study exploring their experiences of involvement in decision-making related to ANH. Convenience sampling via an email advert to the West Midlands Branch of the British Dietetic Association membership enabled participants’ with a range of clinical experience and from a range of clinical settings to be recruited. Interviews were fully transcribed and analysed within an interpretive phenomenological framework van Manen [2]. Ethical approval was obtained from Coventry and Warwickshire Research ethics committee. Results: ‘Wanting to be heard’ was a key theme which was made up from the subthemes of ‘being heard’, ‘trying to listen’ and ‘not being heard’. The sub-theme of ‘being heard’ is reported here. For my participants successful involvement in decision-making meant their voice ‘being heard’. This did not necessarily mean having their view accepted and adopted, but to them it meant being listened to and respected. Participants who were listened to and respected were known by the team and had positive working relationships with them. This was facilitated by have a physical presence in the clinical setting and being seen to make a difference to patient care. Many felt they needed to prove their worth to the team. For my participants, ‘being heard’ was also about speaking up for what they believed was right. For example if it was appropriate to initiate, continue with or withdraw a feed which may be related to end of life situations. Discussion: For these participants positive team relationships were needed to enable them to be heard. Attendance at team meetings where the clinical benefits of dietetic input on patient care could be discussed helped relationships to develop. Time was a barrier to this for some participants. Speaking up about appropriate use of ANH is interesting as implies that participants are not just thinking about ANH as fluid and fuel for the body, but ethical aspects as well. It might be expected that dietitians would promote the initiation and continuation of feeding as they are trained to detect, treat and prevent malnutrition. However, many participants took a more holistic view, showing courage to speak up and ethical sensitivity that it might not be right to feed some patients in certain situations. For some participants ‘being heard’ enabled them to demonstrate expert power. Mandel and Garey’s survey of New Jersey dietitians suggests this is important for dietitians, Mandel and Garey [3]. Conclusion: Dietitians want to have their opinions heard to inform the decision making process. However having opinions respected and listened to appeared to be more important than if their decision which was implemented. Developing relationships with the team and showing clinical benefits of dietetic input on patient care facilitated them ‘being heard’. Time may be a barrier to this. Many participants had the courage to speak up for what they believed was right.
ABSTRACT
Background: Evidence suggests that health care students experience a degree of trauma after experiencing a patient death [1] and they keep their feelings and concerns about patient death to themselves [2]. Rivers, Perkins and Carson [3] suggest that students may be inadequately prepared to deal with patient death during their placements. The aim of this study was to explore dietetic students’ experiences of patients dying whilst on placement. Methods: A qualitative phenomenological approach was used to explore the experiences of 4th year undergraduate student dietitians. Recruitment was opportunistic and data was collected using semi-structured interviews with topic guide and field notes to capture nonverbal communication. Ethical approval was given by Coventry University’s ethics committee and written consent was obtained from all participants. Interviews were audiotaped and transcribed verbatim using thematic analysis as guided by Braun and Clarke [4]. Peer review of findings was undertaken with the second author. Findings: Three female students were interviewed. The main themes identified were: the reaction to patient death, support, personal experience and personal beliefs. The reaction to patient death included feeling shock and upset, as the patient death was unexpected. Participants reported feeling unprepared for their patient’s death. ‘…he was palliative …I didn't really think… he is going to pass away… that was a really difficult one …’ P3. Support was obtained from debriefing to friends or educators or by formal reflection on their experience, which was aided by presenting the patient as a case study. ‘…writing the case study…helped…it’s kind of like you’re thinking about all your actions...almost reflecting on what I’d done… it’s nice to be reassured that I did everything that I should have done.’ P3. However, the students found it difficult to open up to their educators without being prompted to do so. Patient confidentiality was identified as a barrier to debriefing to friends. Reflection was found to be helpful for participants who found it difficult to approach their educators. Participants felt that preparation could only be achieved through personal experience rather than class room discussion. ‘I don’t think the university can prepare you, it’s more about life experience … it’s something you can’t learn in a class room ...’ P1. Personal beliefs helped some participants cope with the experience. Discussion: Students reported being unprepared for death, which was partly due to a lack of experience and because they felt the death was unexpected. Students anticipated patient’s death by the way the patient looked and acted, rather than using the clinical information which indicated the patients ill health; this was a strong contributing factor to the feeling of shock. Student preference for learning about death was through experience is in line with Rivers, Perkins and Carson [3]. The shock of patient death might be reduced by honest discussion by the educators of how ill patients are. The research is limited by a small sample size due to a low response rate; therefore data saturation is unlikely to have been obtained. Conclusion: Students may require support from clinical educators when faced with a patient death but may find this support difficult to access. Clinical educators have a role in supporting students through debriefing, but students may find it difficult to show their feelings. Inviting the student to talk through their experience and offering reassurance may be helpful.