Thursday, 9 December 2010

Tube feeding

Hourglass and figure on a board game
The end of term is nigh, but I am prolonging the agony by extending the time to finish a draft of my project report. Looking on the bright side, I have handed in another piece of work, and if my project report looks reasonable then I'll only have one major assignment for the holidays, as well as revising for the one exam that we have in January. So I might be out walking a lot more over the New Year - last time I was revising so much that I could only spend one day out with friends.

Since Monday there have been two whole days at uni, whizzing through a load more 'stuff that might be useful one day'. Patient safety, a carbohydrate counting exercise, the role of research in dietetics and the value of weight management in groups, some peer-assisted learning about psychosocial factors relating to food choice, going through practice exam questions, and a seminar about the upcoming and final clinical placement.

Meanwhile I handed in the coursework where we had to choose an aspect of dietetic practice and plan a research study as if we had a day a week for 12 months to carry it out. I chose to write about tube feeding in hospital, and how patient-centred our dietetic practice is (or isn't).

It's clearly very important to gain consent for placing the tube, either by passing via the nose or by endoscopic and surgical placement directly through the stomach wall - these are invasive processes, one of which involves an incision. But consent is very rarely gained explicitly for the process of feeding, it seems to be implied by consent to the placement of the feeding tube.

It's the dietitian's job to work out how much feed to give through the tube, and make an initial guess at the right type of feed. There are different types: some more concentrated than others, with and without fibre, and some specialised ones like low sodium or lactose-free. The amount needed is calculated on the basis of the patient's nutritional requirements (usually related to the patient's weight, any stress or trauma, level of activity, and desired weight loss or gain), an estimate of what they are managing to eat by themselves, and any other relevant health conditions. But it is always a guess, and the patient needs to be monitored for change in body weight and any unwanted symptoms like constipation.

What I saw on my last placement was that the 'regimen' for feeding was written up by the dietitian for implementation by nursing staff without any discussion with the patient. Admittedly, when feeding is started the patient is often in no fit condition to express an opinion, and just wants the professionals to get on with it and make them better. But sometimes feeding needs to be continued for a prolonged amount of time, sometimes indefinitely, and in those situations it seems to me that there are choices that ought to be discussed, and aren't.

The main ones are method of feeding and timing. There are two options for tube feeding: you can use a pump that delivers a volume at a constant rate over a defined period of time: 100 ml/hour for 16 hours, for example, which could be overnight or through the day. Or you can 'bolus' feed using a 50 ml syringe, to squirt food into the stomach several times a day over a period of about half an hour each time.

The factors that dictate which method is used seemed to be (a) convenience: it's much easier to set up a feed once a day than manage bolus feeding several times, and (b) it is thought to be more convenient for the patient to be attached to a pump through the night so that there is more freedom during the day. So the default feeding regimen tended to be pump feeding for 16 hours overnight.

I'm not sure that this is what I would want long term. Mealtimes become irrelevant if you're being drip-fed overnight, but they are one of the few things that interrupt the boredom of a prolonged hospital stay. Feeding overnight means that you can't sleep flat - you have to be propped up to make sure the food goes down rather than up. Anyway, my research idea is all about asking patients what they would prefer, and I've handed it in now, so I plan to forget all about it as soon as possible.

Today we had our very last ever lecture on this course! The sobering thought, however, is what the future holds: I have a meeting with my project supervisor and with my placement supervisor, an exam and a viva, a 12-week clinical placement, a couple of revision sessions and the final assessment towards the end of May 2011, and then it's all over! In just six months' time, I may have a job. Interesting times ahead...

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