A preocupante tricotomia na nutrição clínica e sua aplicação aos direitos humanos

  Nutritional support is a major advance in medicine which has made it possible to feed all sick people unable to be orally fed. Failure to anticipate ethical and legal issues as part of the development of technologies such as this can be problematic. This conundrum has been dubbed «the troubling trichotomy» (T3) by the lead author.  El soporte nutricional es un gran avance de la medicina que ha permitido alimentar a todos los enfermos que no pueden ser alimentados por vía oral. Durante el desarrollo de tecnologías como esta, la falta de previsión de las cuestiones éticas y legales puede resultar problemática. El autor principal (T3) ha bautizado este enigma como “la tricotomía problemática”.  O suporte nutricional é um grande avanço na medicina que tem permitido alimentar todos os pacientes que não podem ser alimentados por via oral. Durante o desenvolvimento de tecnologias como esta, a falta de previsão das questões éticas e legais pode ser problemática. O autor principal (T3) batizou esse enigma de “Tricotomia Problemática”

Abordagem ética em nutrição e cuidados paliativos: um enfoque no cuidado de pacientes com demência avançada

Palliative care (PC) is an aspect of healthcare that is receiving increasing attention. As with other areas of medicine, PC is influenced by what can be done technologically, what should be done ethically, and what must be done legally. I.e., the Troubling Trichotomy. This article deals primarily with the ethical perspectives of PC and nutrition. While two of the authors are from the U.S., a third provides a valuable international perspective. A brief introduction on ethics includes a discussion of the components of principalism, currently the most commonly used ethical approach across the world, including the Cartagena Declaration. The success of interventions dealing with PC depend on accountability, communication and teamwork. The various roles of the different stakeholders, including the individual/family/surrogate decision-maker, treating healthcare team, PC team, and healthcare facilities, are discussed. Patient-centered care requires effective communication. In complex cases, a number of specific recommendations by the treating PC team are required to reach this goal. A basic pre-requisite for a successful communication is differentiating PC from hospice care. We review these concepts in detail for patients with advanced dementia, including the definition, signs, symptoms, nutritional needs, and interventions. Since most individuals with advanced dementia are elderly, it is important to note that aging is a process and not a disease, and that it often mimics the signs and symptoms of malnutrition. The responsibilities of the various PC, nutrition, and ethics stakeholders are outlined, followed by an illustrative case with follow-up questions and actions.El cuidado paliativo (CP) es un aspecto de la asistencia en salud que recibe cada vez más atención. Como ocurre con otras aplicaciones de la medicina, el CP está influenciado por lo que se puede hacer desde la perspectiva tecnológica, lo que se debería hacer desde la ética y lo que se debe hacer desde lo legal, es decir, la Triple Perspectiva (Troubling Trichotomy). Este artículo trata principalmente de las perspectivas éticas del CP y la nutrición. Si bien dos de los autores son de Estados Unidos, un tercero ha proporcionado una valiosa visión internacional. Una breve introducción a la ética incluye una discusión de los elementos del Principialismo, enfoque ético más común que se utiliza en la actualidad en el mundo, incluida la Declaración de Cartagena.Os cuidados paliativos (CP) são um aspeto crescente da saúde. Tal como acontece com outras aplicações da medicina, é influenciado pelo que pode ser feito tecnologicamente, o que deve ser feito com ética e o que deve ser feito legalmente, ou seja, a Tricotomia complexa. Este artigo trata principalmente das perspetivas éticas de CP e nutrição. Embora dois dos autores sejam dos EUA, um terceiro forneceu uma perspetiva internacional valiosa. Uma breve introdução à ética inclui uma discussão dos componentes do principialismo, a abordagem ética mais comum usada hoje em todo o mundo, incluindo a Declaração de Cartagena. As intervenções exitosas relacionadas com o CP dependem da responsabilidade, a comunicação e o trabalho em equipe (ACT). São discutidas as decisões tomadas pelos diferentes papéis das partes interessadas, incluindo o indivíduo / a família / e o tomador de decisões encarregado (SDM), o equipe de saúde tratante, o equipe de CP e as instalações de saúde. O cuidado centrado no paciente requer comunicações eficazes. Para cumprir esse objetivo em casos complexos, é necessária uma série de considerações especificamente por parte da equipe de CP na realização de consultas. Um pré-requisito básico das comunicações é diferenciar o CP dos cuidados ao paciente em estado terminal. Esses conceitos são discutidos mais especificamente quando se aplicam à demência avançada (DA), incluindo a definição, sinais, sintomas, necessidades nutricionais e intervenções. Como a maioria dos indivíduos com DA são idosos, é importante observar que o envelhecimento é um processo e não uma doença que muitas vezes pode mimetizar os sinais e sintomas da desnutrição. As obrigações das várias partes interessadas em CP, nutrição e ética são delineadas, seguidas de um caso ilustrativo com perguntas e recomendações

The ethical dimension of nutrition support teams and clinical nutrition professionals in dealing with disease-related malnutrition and access to nutrition care with The Troubling Trichotomy as a foundation

Summary: Nutrition support teams (NSTs) and clinical nutrition professionals (CNPs) have evolved over the years in response to changes in technology, healthcare environment, healthcare financing, and more. Two current challenges facing NSTs/CNPs are the recognition and management of disease-related malnutrition (DRM) and the need for world-wide access to nutrition care. The approach to both previous challenges has been clinical. In this article we explore an ethical additional dimension and propose that a required foundation can be provided by the Troubling Trichotomy (T3) composed of the three pillars which are technology, ethics, and law, adding to the NST/CNP's armamentarium. Most NSTs/CNPs are acquainted with technological advances related to artificially administered nutrition and hydration (AANH) but are not familiar with the nuances of research, publishing, and conflict of interest. The ethical pillar has traditionally focused on the principlism approach and end of life issues. The expanded view includes professional ethics and patient-centered care. Ten legal questions and answers regarding the U.S. legal system are reviewed. Additional needed legal topics such as licensure, top of license practice and the legal ramifications of conflict of interest in reporting, documenting and practice complete the recommended three pillars of the optimal ethical dimension. With the foundation discussed, NSTs/CNPs will be able to manage DRM via awareness, prevention, and management encompassing health promotion and disease prevention. Access to nutrition care as a human right is a pivotal obligation of NSTs/CNPs to provide the right nutrition care for the right individual at the right time in the right way

Nutrition support teams: Institution, evolution, and innovation.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN\u27s efforts. Nutrition support was not administered in some instances by the core of four (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by top-of-license practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right

Beyond nutrition screening: A systems approach to nutrition intervention. Challenges and opportunities for dietetics professionals

Malnutrition in older Americans involves many disparate and complex causes. Dietetics professionals need to broaden their scope of practice in dealing with nutrition screening and intervention themselves and in providing expert consultation to others. Health and social services generalists such as physicians, nurses, and social workers must become more aware of the presence and risk of nutrition-related problems in the elderly and must adopt a systematic, collaborative approach to their solution. Nutrition screening, intervention, appropriate referral, and consultation must be built into daily practice. The NSI is a challenge and a call to action for all dietetics professionals. Registered dietitians must become active participants on interdisciplinary teams. They must assume a leadership role in areas of nutrition screening, assessment, and intervention. Their knowledge, skills, and expertise must continue to keep pace not only with advances in the science and technology of nutrition but also with relevant areas of related fields. The tools provided by the NSI and partnerships between nutrition and other health and social services professionals provide opportunity for the widespread incorporation of a systematic approach to delivery of nutrition services. Attention to nutritional health is too important to be left solely to health specialists or to generalists; all must become active participants in maximizing the nutritional health of older Americans. © 1993 The American Dietetic Association