Hospital Dr News

“Nil by mouth should be action of last resort”

Nil by mouth should be a last resort rather than the first option when caring for patients at the end of their life, an influential working party has recommended.

Its report, called Oral feeding difficulties and dilemmas, is a response to a lack of medical consensus on when artificial nutrition and hydration is appropriate.

The report recommends that oral intake 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.

Nil by mouth should be a last resort and, when tube feeding is necessary, this should be additional whenever possible and done with clear clinical objectives in mind. It found that many care homes across the country are making it a condition of residence that people, often in the advanced stages of dementia, have a tube fitted into their abdomen.

To ensure patient centred decisions about artificial nutrition and hydration are being taken, it recommends that there needs to be a clear agreement about what the aims are of any regimen. Such decisions should never be based on the convenience of staff or carers, it concludes.

Dr Rodney Burnham, co-chair of the working party, hoped the report would bring clarity to a challenging area. He said: “Feeding difficulties can create great uncertainties and even confusion among healthcare professionals, as well as patients and relatives.”

All trusts and care homes to have sufficient staff, especially at meal times, to assist and feed those patients who require a longer time to eat an adequate meal, the report says.

When oral feeding difficulties occur, a doctor-led nutrition support team, should work with patients and their families.

The report was produced by the Royal College of Physicians and British Society of Gastroenterology, and involved a multidisciplinary team of nutritional experts, medico-legal experts and patient representatives.

They heard evidence 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.

The report follows last year’s row over the effectiveness of the Liverpool Care Pathway. The guidance, which describes when fluid and drugs can be withdrawn and sedation used with terminally ill patients, was attacked by a group of senior doctors for encouraging the withdrawal of treatment.

Its aim 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 prevent disagreements.

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