Journal of the Academy of Nutrition and Dietetics
Practice ApplicationsTopics of Professional InterestClinical Ethics and Nutrition Support Practice: Implications for Practice Change and Curriculum Development
Section snippets
Development of Action Statements and Practice Application
A literature review of the past 5 years identified actions that clinicians and hospitals could use to optimize clinical ethics in nutrition support care.2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39 Ten action statements were selected from a list of actions by 22 members of the International Clinical Ethics Section of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) (Figure 1). These
Clinical Ethics Priorities
The common priorities of the action statements reflect a desire to communicate early with individuals/family/surrogates in order to learn their wishes for life-sustaining therapies and obtain advance directives; and incorporate evidence-based medicine addressing potential benefits vs risk/burdens of therapies, along with a proactive consistent health care team approach. Many health care organizations do not yet have reliable systems to engage effectively with individuals to understand their
Transdisciplinary Function
RDN involvement in clinical ethics is supported by the Academy of Nutrition and Dietetics with position and practice papers and an ethics action paper,27, 35, 40 along with an ethics requirement for recertification each 5-year cycle. Clinical ethics requires an interdisciplinary (physicians, RDNs, nurses, pharmacists, speech language pathologists, social workers, chaplains, and other professionals, as appropriate) process and acceptance of discipline interaction to achieve a consistent team
Evidence-Based Evaluation of Benefits and Risk/Burdens of Nutrition Support
The Academy of Nutrition and Dietetics and A.S.P.E.N. have created evidence-based guidelines that evaluate the potential benefits vs risk/burdens of therapeutic nutrition support in a myriad of clinical situations.5, 9, 27, 35 For individuals receiving active therapy for underlying disease and associated physiologic derangements, these guidelines offer guidance for when and how to use nutrition support. Application of clinical ethics is quite straightforward: nutrition support should be
Recommendations for Nutrition Curriculum Design
Different approaches to engage, empower, and educate nutrition support clinicians in clinical ethics might be needed for students in the various disciplines. It is important that students develop an understanding of the four main bioethics principles (autonomy, beneficence, nonmaleficence, and justice), along with cultivating their own moral reasoning skills and communication skills with patients and other disciplines.42 Undergraduate education represents the first opportunity to expose health
Integration of Palliative Care Training into Health Care Clinicians Curriculum
Understanding of palliative care principles and application in the clinical process is critical to improve the ethical practice of initiating, withholding, or withdrawing of nutrition support. With increasing professional and public awareness of the need for humanistic care at the end of life, palliative care has emerged as a priority in medical education.49 Palliative care should not be considered only for an end-of-life focus, but a broader process involving quality of life discussions in
Ranking of Action Statements
Initial application of the recommendations indicated in this article may be limited due to restriction on clinician’s care time and institution financial restrictions. A survey was developed and distributed to rank the action statements and provide an indication of the relative importance for implementation. The results were collected (Figure 2). Additional action statements used in the survey were developed from the work of the Institute for Healthcare Improvement (IHI) in their Conversation
Ranking Variation of Action Statements
Clinicians caring for adult, pediatric, and neonatal individuals had different rankings for clinician ethics action statements. Pediatric and neonatal practitioners ranked “incorporate evidence-based medicine on benefits vs risk/burdens of nutrition support and include ethical decision making into clinical practice” highest. Conversely, adult practitioners ranked “prevent ethical dilemmas with early communication with patient, family, and/or surrogate decision maker about patient wishes for
Recommendations
It is important that clinicians collectively, from all disciplines, focus their efforts on the establishment of clinicians’ actions and institution processes that incorporate the identified actions presented in this article. Prioritizing the implementation of these actions can vary, depending on the specific population and country. The action statements will help address future education programs, materials, and articles in nutrition journals, along with curriculum guidance on the topic of
Acknowledgements
The following participated in the developed and concepts in the manuscript: Deborah Abel, PhD, RD; McCutcheon Adams, LICSW; David A. August, MD; Albert Barrocas, MD, FACS, FASPEN; Carol McGinnis, DNP, CNS-APRN, CNSC; Kelly Alessandro Pontes-Arruda, MD, MSc, PhD, FCCM; and Elizabeth Reis, PhD.
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Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nutrition Support
2021, Journal of the Academy of Nutrition and DieteticsCitation Excerpt :RDNs must have the knowledge, skill, and experience in the application of principles and guidelines in delivering nutrition support, along with general knowledge of all potential comorbidities of a patient/client, in order to appropriately address and provide quality nutrition care and services or know when to confer with or refer to another provider. Since patients/clients requiring nutrition support therapy present with varied and complex treatment issues, the RDN must consider the ethical implications36-38 of nutrition and hydration,39,40 particularly in certain populations, such as those with dementia41 or receiving palliative42 or end-of-life care. Care decisions need to reflect the wishes of the patient/client and/or family/surrogate decision-maker, consistent with an advanced directive that may be in place.
Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Nutrition and Dietetics Technician, Registered
2018, Journal of the Academy of Nutrition and DieteticsCitation Excerpt :NDTRs support members of the interprofessional health care team that provides palliative and/or end-of-life care to adult, pediatric, and neonatal patients/clients. The physician, RDN, or registered nurse is ultimately responsible for communicating to the patient/client, family, guardians, and advocates the risks/burdens of nutrition intervention options and maintaining clinical ethics awareness involving life-sustaining therapies, such as nutrition interventions.45-47 NDTRs:
Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist
2018, Journal of the Academy of Nutrition and DieteticsCitation Excerpt :Are responsible for clinical ethics awareness involving life-sustaining therapies including nutrition interventions, reflecting evidence-based guidelines that evaluate the potential benefits and risks/burdens of therapeutic nutrition support (enteral and intravenous nutrition) in myriad of clinical situations.67,68 Communicate with the patient/client, family, guardians, and/or advocate15 regarding benefits and risks/burdens of nutrition intervention options.67-70 RDNs are leaders in evidence-based nutrition practices that address wellness and disease prevention at all stages of life.
Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition support
2021, Nutrition in Clinical PracticeRole of the Nutrition Support Clinician on a Hospital Bioethics Committee
2019, Nutrition in Clinical Practice
This article was written by Denise B. Schwartz, MS, RD, CNSC, FADA, FAND, FASPEN, a nutrition support coordinator, Providence Saint Joseph Medical Center, Burbank, CA; Nader Armanios, MS, RD, a clinical dietitian, Food and Nutrition Services, Olive View−University of California, Los Angeles, Sylmar; Cheryl Monturo, PhD, MBE, an acute care nurse practitioner—board certified, and an assistant chair and associate professor of nursing and John A. Hartford Claire M. Fagin Fellow, College of Health Sciences, West Chester University of Pennsylvania, West Chester; Eric H. Frankel, MSE, PharmD, a board certified nutrition support pharmacist and a clinical pharmacy consultant, West Texas Clinical Pharmacy Associates, Inc, Kansas City, MO, and Lubbock, TX; John R. Wesley, MD, FACS, FAAP, FASPEN, an adjunct professor of Surgery, University of Chicago, Feinberg School of Medicine, Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL; Mayur Patel, MD, chairman, Department of Medicine and ICU committee, Providence Saint Joseph Medical Center, Burbank, CA; Babak Goldman, MD, palliative care director, Providence Saint Joseph Medical Center, Burbank, CA; Gustavo Kliger, MD, chief, Clinical Nutrition Service and Nutrition Support Unit, Austral University Hospital, Buenos Aires, Argentina; and Emily Schwartz, MS, RD, CNSC, a clinical dietitian, Providence Park Hospital, Novi, MI, and a doctoral student, Clinical Nutrition Program, Rutgers, The State University of New Jersey, Newark.
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT There is no funding to disclose.