Hydration and nutrition at the end of life - Essay Example

Contents Introduction 2 Search Strategy 3 Critique A dis analysis of difficult clinical situations in relation to nutrition and hydration during end of life care (Van Der Riet, et al., 2009) 4 Critique 2: Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients (Adams, et al., 2008) 5 Research Project Plan 7 Research Aim 8 Research Approach 8 Population/Sampling 9 Ethics 10 Data Collection 10 Data Analysis 11 Funding 12 Conclusion 12 References 13 Appendix 1: Database Searches 16 Introduction Nutrition is an essential part of healthcare. It is important in protecting human life and also accelerating the healing process of patients. However, in terminally some special classes of patients, particularly elderly patients and terminally ill patients, nutrition is a very sensitive matter (Mann & Truswell, 2012). This is because palliative care always involve patients who have major sicknesses that modify and change their bodily functions (Pharmd & Grach, 2012). In the case of older patients, there are some bodily functions that lose their efficacy and this requires a high degree of care in varying the diet of patients to ensure a higher quality of life and improve chances of survival (Gillespie & Raftery, 2014). According to standard practice in the UK and Scotland, palliative care and end-of-life healthcare requires a holistic approach through which patients are given the kind of care that influences all aspects of their lives positively (Tappenden, et al., 2013). Therefore, it is important for all aspects of healthcare to be considered and taken into account in order to provide the best of treatment for this category of patients. Furthermore, palliative care and elderly healthcare come with major issues that require the active involvement of the families of patients (Field & Cassel, 2013). This means there is the need for authorisation in an official and unofficial context for the provision of proper care and treatment. In spite of the importance of nutrition in improving the lives of end-of-life patients, evidence indicates that a vast majority of these patients are not given the proper care and attention in terms of feeding and the digestion process (Mann & Truswell, 2012). Over 55% of nurses and medical practitioners do not spend quality time examining and critiquing options for the provision of high quality care (Gillespie & Raftery, 2014). Therefore, patients get major complications that contribute to their challenges at these sensitive times of their lives. The purpose of this research is to examine the main issues with the provision of proper nutrition to persons who are going through end-of-life medical treatments and processes. This will culminate in the examination of a central point in research and from there, Search Strategy In order to design a proper research, there was the need to define the scope of the research and formulate an appropriate strategy to conduct the study. The World Health Organisation (WHO) identified that EOL care is about managing symptoms of acute or chronic situations, educating the patient alongside the family of the patient as well as the caregiver (World Health Organization, 2015). This means that anything relating to nutrition must go beyond just the patient but the family and caregiver. The UK government’s EOL policy paper identified that EOL in Britain relates to an average of 1 million people who die in the country each year and out of this, two-thirds of this are over the age of 75 (Department of Health, 2015). This therefore caused the search to be zoomed into the elderly people in society who are the majority of people who need end-of-life care. The search through the peer reviewed databases was done in two phases. In the first phase, there was a choice of two primary articles. The second phase involved the review of several articles and processes that were necessary. The primary search was done by searching for the key words in Medline and Cinahl databases (further details are presented in Appendix 1 below). These sites are known to have a lot of articles on nursing and healthcare. And they are known to be peer-reviewed. Thus, the journals were more likely to be empirically written and properly vetted. Afterwards, a search of the articles and journals was done. This included the identification of one qualitative research work and another quantitative project. This culminated in the choice of the best articles that were used to draw the main scope of the study. The secondary sources included the variation of the search words for the two databases to find appropriate articles and sources to design the research. Critique 1: A discourse analysis of difficult clinical situations in relation to nutrition and hydration during end of life care (Van Der Riet, et al., 2009) This is a qualitative study that builds on previous publications which indicated the perceptions and discourses of medical professionals – doctors and nurses about nutrition and hydration at the end of life. The study sought to find out how medical professionals managed to care for patients with severe problems like brain injury and compare it to those with terminal illnesses like cancer. This was done within the context of reviewing the conflicts and tensions that occur in discourses at the end of life in the context of nutrition and hydration at this difficult point in life. The sample was purposive rather than convenient and it shows how nurses and doctors actually think about nutrition and care at the end of life. This is to compare incidents where life support (which is often nutrition and hydration) is withdrawn as opposed to situations where a person with a terminal sickness is gradually prepared for death by withholding nutrition and hydration. Although this often happens, different medical professionals have internal and personal conflicts in both situations. The study utilises focus group interviews with nurses and individual open ended interviews with doctors. The sample was taken from practitioners within a series of hospitals. The findings were subjected to discourse analysis and adapted for post-structural frameworks to draw conclusions. The study identified that food and fluids have major emotional and social significance to patients and their families and this often leads to tensions about prolonging life or maintaining a high quality of life for terminally ill patients. The duty of a practitioner is to merge elements of palliative and curative care within the parameters of the competing claims relating to the patient. The findings seem to be ethical as the researchers have exerted a lot of effort in disclosing features and elements of the study and research work they did. However, there is an inherent weakness in the approach which is highly subjective and could lead to inconsistency in the application. The study was not funded and does not seem to be susceptible to so much external manipulation or politics as the journal in question requires researchers to declare conflicts of interest. Critique 2: Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients (Adams, et al., 2008) The research is done through a mixed approach of qualitative and quantitative measures and standards for the analysis and review of pointers relating to health professionals’ perceptions and awareness of signs and risks of malnutrition amongst the elderly population of patients. This includes the use of a statistical method to evaluate the different views and perceptions of people. The sampling is based on convenience since the participants were chosen at random in a six-week period in a major tertiary hospital. However, it provides a rather better and stronger picture of the realities and lends itself to a thorough and critical review. This culminated in selecting 100 elderly patients and 57 health professionals from the ward of the hospital in question. The data was collected from two angles. The first angle included a quantitative and qualitative study which used the Mini Nutritional Assessment. The second part of the fieldwork for the article in question included a questionnaire designed by the researcher to assess the knowledge of the health professionals about how well they knew about nutritional risk categories and themes. The samples of the respondents was appropriate as it provided a broad overview of almost all the practitioners who dealt with elderly patients. It was also thorough enough to cover all nutritional matters over an array of elderly and matured patients. The researchers are taken from a balanced background in nutritional sciences and they had a lot of experience and competency in nutrition and health and could provide a reliable conclusion and research design. Furthermore, there was proper care to take the consent and according to an international standard of research in medical science, monitored by a major Australian university. The study was not funded by any entity and as such, could be viewed as an independent peer-reviewed project. The findings indicate that 30% of the patients were malnourished and 61% were also at the risk of malnutrition. This is evidenced by the fact that a significant percentage of the elderly patients had an actual loss of weight or a loss of appetite. The knowledge of the practitioners in relation to malnutrition risks and loss of appetite was rather poor and could not be ascertained easily this meant the care was bound to be problematic. Thus, there is a problem in the hospitalised senior patients and there is a low rate of recognition by practitioners Research Project Plan Evidence based research requires the evaluation and analysis of pointers from previous research in order to draw conclusions and formulate a research plan (Newell & Burnard, 2011). This is because empirical research must build on a subject studied in a given field in order to establish a framework for data collection and data analysis (Repko, 2011). Thus, the two primary articles reviewed indicated that the administering of nutrition and fluid to patients in palliative care and terminally ill patients is a point of conflict. This is because patients’ emotional attitudes change in such situations and the family has some control in deciding how to administer these things (del Río, et al., 2011; Dev, et al., 2012). Thus, the only solution is to find a mechanism of examining each case individually. Secondly, it is postulated from the primary journal article that elderly patients have a high risk of nutritional problems due to the loss of appetite and general weight loss. This requires special care. This is coupled with the risk that medical professionals often fail to notice the dietary problems of elderly patients. Studies show that the problem of not knowing the best nutritional guidelines is pervasive and it is very much missing from training and practice of many nurses and doctors (Lewis, et al., 2014; Hanks, et al., 2011; Kushner, et al., 2014). A hypothesis is a tentative statement made at the beginning of a research and it is tested for its truthfulness or falsity in the research process (Parahoo, 2014). In order to define the aims of this research, the gaps in the primary research will lead to two hypotheses: H1: Family members intervene in medical professionals’ nutritive prescriptions for palliative and elderly patients and this adversely affects the provision of life-extending and quality-improving nutrition for EOL patients H2: British nurses and doctors fail to check the weight loss, appetite losses and emotional stress of elderly patients. This causes elderly patients to go through adverse situations with reduces the quality of their lives and causes them to die early. Research Aim The aim of the research is to identify the extent to which nutrition of EOL patients is complicated by family intervention and incompetent nurses and doctors in the UK and define the best way of improving nutrition to enhance the quality of life and extend their lives. Research Approach This research is going to be done through a blend of quantitative and qualitative research. This is because the components of the study involve the level of perception and the level of skills of practitioners which are both abstract ideas. Qualitative research is about an identification of how a given phenomenon occurs in real life (Polit & Beck, 2012). Quantitative research on the other hand, is a numerical based analysis of the variables of a given research (Tappen, 2010). Quantitative research is about identifying the values and providing a statistical aggregation and interpretation of the findings. Therefore, this study will be divided into three main phases to evaluate the two hypotheses above and also draw conclusions on the best way of improving nutrition in palliative care and elderly care. A summary of the phases are Phase 1: Ascertainment of the role of family members in defining nutrition of EOL patients Phase 2: Identification of awareness and performance of nurses and doctors in providing nutritive care to EOL patients Phase 3: Definition of a model for the improvement of nutrition amongst EOL patients Phase 1 will identify how the families of EOL patients intervene or interfere in the delivery of high quality nutrition amongst EOL patients in the UK. This will be followed by Phase 2 which will seek to identify the inherent limitations in the medical system and how it affects the quality of life and length of life of EOL patients. Phase 3 will seek information from qualified and learned persons on how to improve the status quo and enhance the nutrition of patients in British hospitals and medical facilities in order to extend the life of EOL patients and improve the quality of life they will have in the last days of their lives. Population/Sampling A total of 100 respondents will be made to participate in an email survey for the first phase of the research. This will include principal members of families who represent EOL patients in the UK. The sample of 100 respondents will be taken from the NHS database and will include relatives of EOL patients who have volunteered to give information and participate in surveys. The method of sampling will be a probabilistic sample which will include a careful and fair representation of members from different parts of the UK (Gerrish & Lathlean, 2015). This is opposed to non-probabilistic sampling which involves random selections that could lead to biases and issues of over-concentration on certain parts of the UK (Fain, 2013). The sample for the quantitative research will include 4 hospitals that will be studied in the UK. This will be done by random sampling. One hospital will be taken from London, another from the south of England, another from the Midlands and the last from the north of England, Wales or Scotland. Their statistics will be analysed and compared in order to draw logical conclusions and inferences. For each hospital, the EOL units will be studied and evaluated. The standard for choosing the two respondents for the last phase will include 10 years of postgraduate experience in nutritive care amongst EOL patients. They could be from any part of the UK and should have a broad understanding of how nutrition matters are handled in EOL settings in the UK. Ethics The main ethical issue is with the confidentiality of information. There is a risk with the family of patients. This will be handled by inviting only members on the NHS database who have offered to participate in research. Also confidentiality of information from the healthcare facilities and the EOL professionals in the third phase will be protected by the Data Protection Act 1998. This will include the secure and confidential use of privileged and sensitive information. Data Collection The research will seek to generalise trends and patterns in medical care in Britain. Therefore, the gathering of information should be of a wider scope and must cover as many facilities as possible. There are different categories and levels of medical facilities in the UK. The families of patients in the UK are scattered around the country. This includes general practitioners, specialised entities, large hospitals and medium to small facilities (Care Quality Commission, 2015) Therefore, there might be the need to gather information in the most extensive form possible. Thus, an electronic data collection system might be much more appropriate. This can be done through an online survey sent to the emails of the respondents. Concerning medical practitioners, palliative care and elderly care is a fairly specialised field of practice. Thus, there is the need to go to medical facilities to conduct various forms of statistical analysis. This will be collected and input into an SPSS system and analysed to draw conclusions. This will include mathematical data on three main things 1. The level of experience in nutritional matters (to be measured in number of years of training and scope of areas studied) 2. The inclusion of nutritional matters in EOL care (the financial worth of nutritional decisions and choices and levels of staff members who play roles in nutritional matters) and 3. The quality of life EOL patients and average expectancy (number of years patients live on the average per cases [in palliative care] and per ages [75+ for elderly patients]) For advisory information in the third phase, there will be an interview with two individuals who are experienced and well informed about nutritional practice in EOL practice. This will be a set of open ended interviews that will include several questions. This will provide qualitative information about how nutrition can be improved and from there, there a model can be formulated for the improvement and enhancement of nutrition for the best of results amongst EOL patients. Data Analysis Data for the first phase will be compiled through the use of a visual impression to gather and sort information. Majority trends and significant minority trends and patterns of family members’ role in deciding the nutrition of their EOL relatives. Data for the second phase will be processed by an SPSS software and the means and averages will be done through correlation and regression. This will show averages and from the averages, the main patterns in the education and experience of nutritional care in EOL care will be identified and gaps will be drawn. The gaps will form the basis of the questions for the last phase and they will modify the primary questions for this phase where necessary. This will be presented to the respondents and their findings will be transcribed and used as a basis for the formulation of conclusions on how to improve nutritive care amongst EOL patients. Funding There will be no external funding for the research. The research costs will be kept as low as possible and save for grants below £250 for miscellaneous educational expenses, there will be no external help for this study Conclusion This research will include the gathering of information to answer the two hypothesis relating to family involvement in nutritive choices of EOL patients in Britain and nurses/doctors’ deficiencies in administering EOL nutritive solutions appropriately. The findings will lead to gaps that will be presented to professionals in the field to provide information about possible and credible solutions to the problem. This research will have practical applications in improving the British healthcare system. References Adams, N. E. et al., 2008. Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients. Nutrition & Dietics, Volume 65, pp. 144-150. Care Quality Commission, 2015. Quick reference guide to regulated. [Online] Available at: http://www.cqc.org.uk/sites/default/files/20150209%20100521%20v5%200%20Quick%20reference%20guide%20To%20Regulated%20Activities%20by%20Service%20Type_FOR%20PUBLICATION%20%282%29.pdf [Accessed 25 November 2015]. del Río, M. I. et al., 2011. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Journal of Psychological, Social and Behavioral Dimensions of Cancer, 21(9), pp. 913-921. Department of Health, 2015. 2010 to 2015 Government Policy: End of Life Care. [Online] Available at: https://www.gov.uk/government/publications/2010-to-2015-government-policy-end-of-life-care/2010-to-2015-government-policy-end-of-life-care [Accessed 25 November 2015]. Dev, R., Dalal, S. & Bruera, E., 2012. Is there a role for parenteral nutrition or hydration at the end of life?. Current Opinion in Supportive & Palliative Care:, 6(3), pp. 365-370. Fain, J. A., 2013. Reading, Understanding, and Applying Nursing Research. London: FA Davis Publishing. Field, M. J. & Cassel, C. K., 2013. Approaching Death:: Improving Care at the End of Life. 4th ed. Washington, DC: National Academies Press. Gerrish, K. & Lathlean, J., 2015. The Research Process in Nursing. Hoboken, NJ: John Wiley and Sons. Gillespie, L. & Raftery, A. M., 2014. Nutrition in palliative and end-of-life care. British Journal of Community Nursing, 19(7). Hanks, G., Cherny, N. I., Christakis, N. A. & Kaasa, S., 2011. Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press. Kushner, L. et al., 2014. Nutrition education in medical school: a time of opportunity. The American Journal of Clinical Nutrition, 99(5), pp. 213-219. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. & Bucher, L., 2014. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. London: Elsevier Health Sciences. Mann, J. & Truswell, S., 2012. Essentials of Human Nutrition. 2nd ed. Oxford: Oxford University Press. Newell, R. & Burnard, P., 2011. Research for Evidence-Based Practice in Health 2nd ed. Wiley -Blackwell. 2nd ed. London: Wiley. Parahoo, K., 2014. Nursing Research: Principles Process and Issues. 3rd ed. England: Palgrave Macmillan . Pharmd, P. V. & Grach, M. C., 2012. Nutritional support and quality of life in cancer patients undergoing palliative care. European Journal of Cancer Care, 21(5), pp. 581-590. Polit, D. & Beck, C., 2012. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Beijing: Wolters Kluwer Health.. Repko, A. F., 2011. Interdisciplinary Research: Process and Theory. New York: SAGE. Tappenden, K. A. et al., 2013. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. Journal of the Academy of Nutrition and Dietetics, Journal of Parenteral and Enteral Nutrition, 113(9), p. 1219–1237. Tappen, R. M., 2010. Advanced Nursing Research. New York: Jones and Bartlett. Van Der Riet, P., Higgins, I., Good, P. & Sneesby, L., 2009. A discourse analysis of difficult clinical situations in relation to nutrition and hydration during end of life care. Journal of Clinical Nursing, 18(14), pp. 2104 - 2111. World Health Organization, 2015. Palliative care: Symptom management and end-of-life care. [Online] Available at: http://www.who.int/hiv/pub/imai/primary_palliative/en/ [Accessed 25 November 2015]. Appendix 1: Database Searches The search for the word “nutrition in palliative and end-of-life care” was already one of the default choices and it yielded 371 results in the Medline sources The same words were repeated for the Cinahl database website and yielded 198 sources which were used as the basis for the conduct of the primary research. Read More