A guide to practical care, particularly towards the end of life.
A multidisciplinary nutrition support team of healthcare professionals, ideally but not inevitably led by a doctor with special expertise in nutrition, should be available to work with patients and their families when oral feeding difficulties occur. A member of the team should be available by telephone at weekends as well to provide advice.
Such teams should be collaborative in nature and not be made up of independent professionals who are focussed only on their area. The patient should be at the centre of their efforts.
The first question should be ‘what are we trying to achieve’?
Oral intake, modified as necessary, should be the main aim of treatment. Nutrient-dense foods or special provision of food (in hospital the ‘red tray’ system) is helpful.
Even when tube feeding is necessary, this should be additional whenever possible. At the end of life, even if deemed to have an ‘unsafe swallow’ a risk management approach may offer the patient the best quality of life. If in doubt, a trial of nasogastric feeding with clearly agreed objectives may be appropriate. Tube feeding should then be withdrawn if failing to achieve the objectives. ‘Nil by mouth’ should be a last resort, not the initial default option.
When artificial nutrition and hydration are required for the medium term or longer, this should be managed by the multidisciplinary team together with other health professionals, the patients themselves and their family/carers, at home if possible. The setting may be a care home if the patient has other medical problems.
All trusts and care homes should ensure there are sufficient staff, especially at mealtimes, to assist and feed those patients who require a long time to eat an adequate meal.
The full facts of the situation should be understood by all involved to enable a patient-centred decision about artificial nutrition and hydration and the means of delivery. This should never be based on the convenience of the staff or carers or be required as a criterion for admission by any institution. We believe that to be unethical and bad practice.