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Nil by mouth - a last resort. This is the central message from a Working Party report published by the RCP (London) and the British Society of Gastroenterology

Entitled, ‘Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life’, it has been prepared in response to continuing unease about the lack of consensus, including among doctors, about when artificial nutrition and hydration is appropriate.

Its authors (a multidisciplinary team of healthcare professionals with an interest in nutrition matters, medico-legal experts and patient representatives) have reviewed the clinical and ethical arguments surrounding the tube feeding of those patients who, often near the end of life are experiencing swallowing difficulties either as a result of neurological illness or other substantial disabilities.

The ultimate aim of the report is to improve care by providing healthcare professionals, patients, their families and carers with practical advice that has a sound legal and ethical basis, and to prevent distressing and complicated disagreements.

The Working Party invited a wide range of stakeholders to submit views during the course of the work. Among the evidence they took were reports of poor practice involving the withdrawal of feeding, as well as its inappropriate continuation. There were also reports of substantial disagreements between health professionals and family members when patients were unable to articulate their wishes.

On the basis of this, the group’s final recommendations are that:

• Oral intake, modified as necessary, should be the main aim of a nutrition strategy at the end of life. Even if a patient is deemed to have an ‘unsafe swallow’, a risk management approach may offer them the best quality of life; ‘nil by mouth’ should be a last resort, rather than the initial default option. Where tube feeding is necessary, this should be additional whenever possible and done with clear clinical objectives in mind.
• To ensure patient centred decisions about artificial nutrition and hydration are being taken, there needs to be a clear agreement about the aims of any regimen. Such decisions should never be based on the convenience of staff or carers, nor should artificial feeding ever be required as a criterion for admission to any kind of institution providing care.
• All Trusts and care homes should ensure there is sufficient staff, especially at meal times, to assist and feed those patients who require a longer time to eat an adequate meal.
• When oral feeding difficulties occur, a nutrition support team, ideally but not inevitably led by a doctor with special expertise in nutrition, should be made available to work with patients and their families.

Dr Rodney Burnham, Co-Chair of the Working Party said: “This report brings considerable and much overdue clarity to a very challenging area. Feeding difficulties can create great uncertainties and even confusion among healthcare professionals, as well as patients and relatives. The College expects it to become an invaluable resource for those who are trying to grapple with these difficult issues.”

Dr David Sanders of the British Society of Gastroenterology said:
'The British Society of Gastroenterology is strongly supportive of this timely and critical report. This report not only provides an evidence base for our practice but is also a valuable 'working manual' for clinicians from all disciplines dealing with these highly emotive clinical problems. This report is further strengthened by the fact that it was an all inclusive working party which encompassed many disciplines and societies.”

Copies of the report are freely available for download in the members’ section of the website, or for sale in hard copy or pdf format to non-RCP members through the College’s online bookshop.

BGS Newsletter, February 2010
Issue 25 ISSN 1748-634000 25