Eating at Risk within Long-Term Care: A Case for the Relational Ethics Lens.

Within long-term care homes (LTCHs), conflicts occur between residents' desires, LTCH constraints, and healthcare providers' concerns about risks of harm. Due to the high prevalence of dysphagia and malnutrition in these settings, decisions regarding food choices are a common source of such tensions. Existing biomedical ethical models fail to capture the complexity of the interprofessional chronic care environment. This article proposes an alternative ethical lens, the relational ethics model. We describe a case illustrating the application of a decision-making framework with a relational ethics lens for a resident with severe dysphagia and malnutrition. We highlight how the bioethics model excludes important actors from ethical decision making. We encourage registered dietitians working in LTCH to incorporate a relational ethics model into their practice to help identify resident's values and bring attention to the interconnectedness of caring relationships and contextual factors. This approach can inform difficult decisions regarding the food and nutrition choices of residents and may facilitate meaningful outcomes for both individuals and the long-term care community.

Participant diversity in clinical trials of rehabilitation interventions for people with multiple sclerosis: A scoping review.

BACKGROUND: The selection and description of participants in clinical trials enables health care providers to determine generalizability of findings to the populations they serve. Limited diversity of participants in trials restricts evidence-based decision-making. OBJECTIVES: To determine the extent to which diverse participants are being included in clinical trials of rehabilitation interventions for people with multiple sclerosis (MS). METHODS: We conducted a scoping review of MS rehabilitation trials published since January 2002 using MEDLINE, CINAHL, and Web of Science. Covidence was used to facilitate the review. Article selection required randomized control design, a rehabilitation intervention, and a functional status outcome. Data extracted included details of intervention(s), outcomes, and participant selection and description using a social determinants of health framework. RESULT: A total of 243 studies were included. Exercise interventions and impairment-focused outcomes were most common. Most studies used only a MS Clinic for recruitment. Common exclusion criteria were physical or mental comorbidities, disability, age, and cognitive impairment. Participant age and sex were reported for almost all trials; reporting of other social determinants of health was atypical. CONCLUSION: MS rehabilitation trials have used limited recruitment methods, restricted samples, and reported few participant descriptors. Changes are required to enhance participant diversity and the descriptions of participant characteristics.

Incorporating handgrip strength examination into dietetic practice: A quality improvement project.

Protein-energy malnutrition is both prevalent and costly within the inpatient rehabilitation population. Registered dietitians play a key role in identifying, diagnosing, and treating protein-energy malnutrition. Handgrip strength has been shown to correlate with clinical outcomes, including malnutrition. Reduced handgrip strength is included as a criterion in national and international consensus guidelines of malnutrition diagnoses for functional changes. However, limited research and quality improvement projects have reported on its actual use in the clinical setting. The purpose of this quality improvement project was to (1) implement handgrip strength testing into dietitian care on three inpatient rehabilitation units to allow dietitians to identify and treat nutrition-related muscle function losses and (2) evaluate the feasibility, clinical utility, and clinical impact of this project. This quality improvement educational intervention demonstrated that handgrip strength is feasible, does not impact dietitian efficiency, and is clinically useful. Dietitians reported three areas in which handgrip strength provided value: assessing nutrition status, motivating patients, and monitoring responses to nutrition interventions. Specifically, they were able to shift away from focusing solely on change in weight to focusing on functional ability and strength. Although outcome measures demonstrated favorable outcomes, the results must be interpreted cautiously because of the small sample and pre-post uncontrolled design. Further high-quality research is required to provide more in-depth information on the utility and limitations of handgrip strength as an assessment, motivational, and monitoring tool for clinical dietetics.

High costs and limited dietitian services for home enteral nutrition users: A Canadian study.

BACKGROUND: Home enteral nutrition (HEN) is the provision of nutrition through a tube outside the hospital. The Canadian prevalence of HEN is not previously well understood. This study aimed to (1) describe the demographics and healthcare usage of HEN in adults in a Canadian health authority, (2) compare the proportion of HEN-related hospital visits between patients who did and did not receive a community registered dietitian (RD) follow-up, and (3) determine associations between demographic and healthcare usage of HEN adults . METHODS: A retrospective chart review was conducted on the records of HEN patients with a tube placed between April 1, 2012, and March 31, 2015. Descriptive and comparative statistics were applied. RESULTS: A total of 390 adults were discharged receiving HEN. The majority (74.9%, n = 271) of the sample did not have any record of visiting a community RD up to 6 years after tube placement. Fifty-three percent of the sample visited the hospital for HEN-related complications, costing CAD $14,324,465.00 (USD $10,677,946.00) to the healthcare system. Multiple regression analysis revealed that females ( P < .05), jejunostomy tubes ( P < .05), and older age ( P < .05) were associated with more hospital or emergency room visits. CONCLUSION: This study found a higher prevalence of HEN patients and more varied demographic and clinical characteristics than previously reported. The healthcare costs per patient per year exceed previous reports. Further research is needed to explore the population's experiences and develop interventions that improve gaps in the healthcare system.