“Nil by mouth” should be the last resort, rather than the first option, is the central message of a report published by the Royal College of Physicians and the British Society of Gastroenterology. Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life has been prepared in response to continuing unease about the lack of consensus on when artificial nutrition and hydration is appropriate.
Its authors (a multidisciplinary team of healthcare professionals with an interest in nutrition matters, medico-legal experts and patient representatives) have reviewed the clinical and ethical arguments surrounding the tube feeding of those patients who, often near the end of life, are experiencing swallowing difficulties either as a result of neurological illness or other substantial disabilities.
The aim of the report is to improve care by providing healthcare professionals, patients, their families and carers with practical advice that has a sound legal and ethical basis, and to prevent distressing and complicated disagreements.
A Working Party invited a wide range of stakeholders to submit views during the course of the work. Among the evidence collated were reports of poor practice involving the withdrawal of feeding, as well as its inappropriate continuation. There were also reports of substantial disagreements between health professionals and family members when patients were unable to articulate their wishes.
On the basis of this, the Working Party recommended that oral intake, modified as necessary, should be the main aim of a nutrition strategy at the end of life. Even if a patient is deemed to have an “unsafe swallow”, a risk management approach may offer them the best quality of life.
Where tube feeding is necessary, this should be additional whenever possible and performed with clear clinical objectives in mind. Such decisions should never be based on the convenience of staff or carers. The group also said that artificial feeding should not be required as a criterion for admission to any kind of institution providing care.
All Trusts and care homes should ensure there is sufficient staff, especially at meal times, to assist and feed those patients who require a longer time to eat an adequate meal. When oral feeding difficulties occur, a nutrition support team – ideally led by a doctor with special expertise in nutrition – should be made available to work with patients and their families.
