Improving the care of patients feeding at risk using a novel care bundle

Abstract

Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with signifi cantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The signifi cance and applicability of these fi ndings is discussed.

Health professionals' perceptions of complex feeding decision‐making in school‐aged children

“…It is common in children with complex needs. 6 This practice is often associated with prioritising comfort, reducing distress and respecting autonomy. 7 While current literature focuses on the use of evidence-based assessments and interventions for children with PFD, 8 there is considerably less research focus on decision-making.…”

“…Risk feeding or feeding with established risk is defined as continuing to eat and drink orally with the understanding that it will increase the risk of aspiration and thus pneumonia. It is common in children with complex needs 6 . This practice is often associated with prioritising comfort, reducing distress and respecting autonomy 7 .…”

Risk feeding in the advanced stages of Parkinson's disease

“…Alongside a flowchart ( Figure 1), information leaflets on risk feeding are created for staff and for patients and their carers and a FOR-WARD-branded swallow advice poster for display above patients' beds is created. 7 In our hospital, over a six-month period, we observed three cases of PD patients (median Hoehn & Yahr stage 5 (range: 0-5)) fed at risk who remained NBM for a number of days (median (IQR) days NBM: 2 (1.5-5.5)) without alternative enteral nutrition before a risk feeding decision was undertaken (Table 1a). This was found to be due to a failure of health care professionals meeting to discuss patients' best interests and delayed or incomplete assessment of patients' views and capacity.…”

The challenge of making better decisions about oral intake in older people with ‘aspiration pneumonia’

“…Yoshimatsu and colleagues, among others, have noted the lack of agreed diagnostic criteria for AP in the literature and in clinical practice, that the labelling of pneumonia as AP occurs primarily in older patients with greater comorbidities [1][2][3], and they have argued-convincingly in my viewthat 'frailty-associated pneumonia' would be a preferable and more accurate term [4]. They have also been among the pioneers of what are sometimes termed 'risk feeding' policies and pathways [5,6]. These aim to facilitate and encourage a normal diet, even if there are difficulties with eating and drinking, when this is what patients want or when this is most consistent with their comfort.…”