1 | P a g e Decision Making Guidelines for Long Term Medically Administered Nutrition (These Guidelines are not intended to replace professional judgment) Patient is not eating.
CATEGORIES A, B & C Category A No Dysphagia but nutritionally compromised and unable to meet requirements orally. MAN likely to: 1. Be of clinical benefit and achieve patient goals 2.Improve quality of life. 3. Be required long‐term (>4‐6 weeks) CATEGORIES D & E Category D* Dysphagia associated with significant co‐morbidities & poor quality of life due to progressive underlying disease
Category E* Vegetative State/Prolonged Coma. Category C Select cancers with non‐
functioning GI tract but good quality of life & performance status Consider Medically Administered Nutrition Category F*
Dysphagia associated with significant co‐morbidities and poor quality of life due to severe dementia Category B Dysphagia associated with non‐progressive deficits & good quality of life (e.g. brain injury or stroke with reasonable likelihood of recovery CATEGORIES F & G
Discuss long term MAN vs withholding feeding. Consider Clinical Ethics Consult to assist with decision
* See “Legal Consultation” on page 3. Category G*
Advanced Terminal Disease /Anorexia‐cachexia syndrome associated with nutritional deficit refractory to nutritional therapy (e.g. advanced cancer, advanced AIDS, related non‐functioning GI tract) Do not offer Medically Administered Nutrition
2 | P a g e Rationale of Guideline Recommendations for Medically Administered Nutrition CATEGORIES A, B & C Categories A, B & C represent clinical situations where the patient/resident is likely to benefit from long term medically administered nutrition (MAN). To ensure that there is informed consent, the physician should discuss the advantages and disadvantages of long term MAN with the patient/resident/ substitute decision‐
maker (SDM) and explain what would be involved in the procedure for insertion of an enteral or parenteral access device. CATEGORIES D & E* Categories D & E represent clinical situations that are ethically and clinically complex due to the uncertainty regarding whether MAN will, on balance, constitute overall benefit or overall harm. Clinicians will need to weigh potential benefits of enterally‐based MAN and the likelihood of improved quality of life. For these categories, the physician should discuss with the patient/resident/SDM the advantages and disadvantages of long term enterally‐based MAN and what is involved in the procedure for insertion of an enteral access device. Additionally, the physician should communicate that it is an option to withhold or withdraw MAN and what this will mean for the patient/resident. If there is any conflict between the stakeholders a Clinical Ethics Consultation should be considered. The following questions can assist in determining the appropriateness of long term enterally‐based MAN: 1. Is it consistent with the patient’s/resident’s values and preferences? 2. Will it improve the patient’s/resident’s quality of life? 3. Will it result in a physiological or clinical benefit to the patient/resident and family? 4. Will it help to achieve the overall goals of care? If the risk/benefit ratio is unclear, or the evolution of the disease is uncertain, consider a trial with nasogastric tube feeding, with withdrawal if little or no benefit is demonstrated. CATEGORIES F & G* Categories F & G represent situations where the patient/resident is unlikely to experience any clinical benefit from MAN. In these cases, long term MAN is not recommended and the physician must communicate to the patient/resident/SDM the rationale for why it is not recommended (e.g. review how potential disadvantages outweigh the advantages). The physician must communicate that it is clinically appropriate to withhold or withdraw MAN. For patients/residents who have dysphagia, the discussion will also include the concept of the right to live “at risk”. Some patients/residents, however, may choose to continue oral feeding, with or without MAN, even though they are at risk of aspiration. The health care provider must discuss the risks associated with continued oral feeding with the patient/resident/ SDM to ensure an informed decision is made. * See “Legal Consultation” on page 3. 3 | P a g e Potential Advantages •
Maintain or improve nutritional status and assist with maintaining hydration •
Maintain or improve physical condition •
Maintain or Improve mental functioning •
Maintain or improve quality of life, which includes social, spiritual and emotional well‐being •
Maintain life for a period while the decision‐maker/family makes end‐of‐life decisions •
Prolonged life may be an advantage depending on quality of life and cultural perspectives Potential Disadvantages •
Prolonged pain, suffering, discomfort, and debility from a lengthened illness or disease process. •
A reduced quality of life, which includes a negative impact on emotions and other social factors. •
The introduction of other forms of suffering (such as immobility from physical pain or chemical restraints used to prevent tube removal by patients/residents) •
Irritation and infection at tube insertion sites, dislodgement, clogging, or other tube related problems. •
Aspiration, aspiration pneumonia, and tube feeding intolerance. Legal Consultation Each case is context and facts specific. In cases where disagreement persists between the care team and the patient/resident/SDM over decisions of withholding or withdrawing medically administered nutrition, and where other forms of mediation (Patient Relations, Ethics, Administration, etc) fail, teams should consult with the organization’s legal counsel. * See “Legal Consultation” on page 3.