Book Description

Background: For patients who have severe and chronic dysphagia, decisions need to be made about the provision of nutrition and hydration. 'Risk feeding', where a patient continues to eat and drink despite risk, may be necessary in situations where enteral tube feeding is not thought to be in a patient's best interests or is not medically possible. There is emerging interest in risk feeding pathways internationally. This retrospective audit explored current complex feeding decision practices in one medium sized New Zealand hospital. Methods: Fifty patients identified at daily ward rounds across a 15-month period as involving a feeding decision were recruited. Feeding decision was defined as: an oral or non-oral feeding decision made for the continuing provision of nutrition for severe oropharyngeal dysphagia not expected to resolve during hospital admission. For each identified patient, all discharge summaries, both historical as well as future admissions (up to and including six months post recruitment) were audited. A total of 149 admissions were tallied. All episodes of care where dysphagia or dysphagia-related complications were reported as a primary or secondary diagnosis in the discharge summary were included. Inclusion terms used: dysphagia, swallowing difficulty, diet modification, chest infection. Results: Fifty patients (76% male) were included (mean age 75yrs, range 19-94, SD 14.9) including 103 admissions for dysphagia-related illness (mean admission per patient 2, range 1-16) across a range of specialities: medical, surgical, stroke, oncology and rehabilitation with a mean length of stay of 18 days (range 1-139, SD 22). Only 24% of admissions involved palliative care. Sixty percent of admissions included enteral tube feeding. Of 49 nasogastric tubes placed, 31 (63%) failed. Nil-by-mouth with total enteral tube feeding was the final feeding decision in only 11% of admissions, while, 54% of admissions led to a risk feeding decision. Dysphagia was documented in only 44% of discharge summaries; with a feeding decision documented in only 34%. Conclusions: Management of feeding decisions for patients with severe oro-pharyngeal dysphagia is complex. Convoluted, lengthy decision-making with failed enteral feeding trials is common. Omissions in transfer information regarding dysphagia and feeding decisions potentially affect continuity of care. The findings from this study support the development of an evidence-based clinical guideline for the management of risk feeding decisions.