Tuesday, 7 September 2010

First week of consolidation

Bottles of nutritional supplements on shelves
I have been deemed fit for purpose and given three wards to look after on my own, which amounts to between six and ten patients. If I come across anything complicated on the wards, I bleep a grown-up dietitian. I also have to run a radiology clinic, a general dietetic outpatient clinic, give an assessed presentation about healthy eating with Gestational Diabetes to a room full of pregnant women (which I've done, and it went very well), and do an assessed presentation about my case study.

It's not bad. I have been asked a few times if I'm enjoying it, and still the answer is no. I think that to enjoy myself, I must be able to relax, and there's not a moment when I can do that. On the wards I inspect the notes minutely so as not to miss anything, and usually ponder for some time before deciding what to do. This is in a ward where people are buzzing around with bulging files and stethoscopes and bedpans and mops and wheelchairs and drip stands and walking frames, and the myriad sets of notes and documentation could be anywhere and might be taken away the moment I find them. It's not a calm and peaceful environment where I can peruse the case carefully and consider my decision at length.

One patient last week took me 90 minutes from start to finish, which included reviewing the medical and nursing notes and all the charts, calculating nutritional requirements, formulating a feeding regimen that ramped up over several days and included fluids, prescribing the right feed in the right format on the drug chart, planning the whole intervention and documenting it unambiguously in the medical and dietetic notes. Add to that the challenge of finding all the supporting information, and it's clear why patient contact can take so long for a beginner.

Two patients referred to me for dietetic advice last week were discharged back home, one of them before I'd actually seen her. A decision had to be made about whether to take any follow up action, like writing to the GP or inviting the patient to an outpatient clinic for subsequent dietetic advice. These two cases provoked some interesting discussion in the office about the practice of prescribing supplements for people leaving hospital.

One was an elderly lady, frail as a cobweb, who'd been admitted with an infection and confusion. The other was a previously malnourished man whose oesophageal stent had shifted, preventing food from reaching his stomach. Both were discharged 'well', i.e. without infection and with the stent replaced where it should be.

The criteria for prescription of oral supplements are that the person must have one of several specific conditions, mostly gastro-intestinal diseases that impair absorption of food within the gut.* There is one generic condition given in the British National Formulary (the rules for prescribing medication): disease-related malnutrition. Neither of these patients met the criteria: the old lady because she had no disease, and the man because he was no longer malnourished. But she was clearly not eating well, while he loved his supplements and had talked the ward into giving him a big bagful to take home.

I talked to the man about his food intake, and how he is using the supplements he had previously been prescribed at a level of two bottles a day. His wife cooks him a proper meal in the evening, but for the rest of the day he relies on these bottles of supplements. Up to six of them in a day, and up to two supplement soups that perhaps he had persuaded his GP to prescribe without our input.

"If I wake up hungry in the night," he said, "I might have one then."

"But they are medicine," I told him. "You don't take medicine for a condition you don't have, just because you like it, do you? If you wake up in the night, you could have a cup of cocoa instead."

"I don't like cocoa," he replied.

"Well, have some tea, or toast, or a sandwich," I said. "These supplements are not simply for your convenience."

"I have them because they make me feel better. They give me the strength to eat my dinner."

We would have liked to prescribe supplements for the little old lady, who would surely not manage to eat well on her own. We could imagine the man persuading his GP to continue prescribing more supplements than are strictly required. My supervising dietitian has written a very carefully worded letter to his GP to say that there is no justification for this. It's our taxes that pay for it, after all.

I wake up thinking about individual patients that I've been seeing. I find myself mulling over calculations and assumptions that I've made. Consolidation continues this week. I'm still not enjoying it, but it's better than the ten weeks that went before.

* Short bowel syndrome, intractable malabsorption, pre-operative preparation of patients who are undernourished, proven inflammatory bowel, following total gastrectomy, dysphagia, bowel fistulas, continuous ambulatory peritoneal dialysis, haemodialysis.


Studentmum said...

I think that note reading, assessing & prescribing will get quicker the more it's done. Also I think your pts misuse of feeding supplements happens because of the lack of monitering, due no doubt to lack of funds & personal. If it makes him feel better, he can't be blamed really. Nutrition in the frail elderly at home and in hospital is a huge issue - highlighted by the fact she is well so denied supplements that will keep her that way. It would be more cost effective to keep her well, surely?

Lola said...

The thing is that food will keep her well, and food is what she needs. Supplements, as the name implies, are not intended to replace food.

There are many more appropriate sources of help, including family, friends and social services (e.g. meals on wheels), all of which are the right way to help an elderly person enjoy eating, rather than sitting all alone sipping at a bottle of sickly sweet liquid that tastes faintly metallic because of the minerals in it.

Studentmum said...

I agree, 'food' is what she needs and in an ideal world she would have access to that food, with friends & family, social services etc to help her shop for, prepare and eat that food. Meals on wheels yes - but only if she asks for them and actually allows the service to deliver (experience with stubborn in-laws enables me to say that the elderly do not always accept the help that is offered/available to them)- there are so many factors involved with making sure the frail elderely get adequate nutrition. However, I do agree supplements are not the best, nor the entire answer.