Clinical Practice: Acute & Chronic Care

Clinical Work Settings What are the major job settings for clinically-based dietitians? 1. Health care facilities -- Acute care/in-patient care -- hospitals -- day-care/day-hospital settings -- extended care facilities -- chronic care settings -- physician clinics/ambulatory clinics SHOW fig 8-1, p. 138 -- dietary dept organization examples Separate dept -- increase visibility as unit distinct from food service With Food Services -- allows coordination of patient food choices and menus

Clinical Work Settings Health care facilities Acute care/in-patient care short term care delivered to patients who experience sudden illness or trauma Long term care managing chronic conditions Ambulatory clinics managing chronic conditions or disease prevention in community dwelling

Responsibilities in Clinical Dietetics Nutrition Screening Nutrition Assessment Nutrition Care Plan Monitoring Progress Nutrient Analysis

Responsibilities in Clinical Dietetics Nutrition Screening Screening process to identify nutritional risk

Nutrition Screening Example Disease Eating poorly Tooth loss or mouth pain Economic hardship Reduced social contact Multiple medications Involuntary weight loss or gain Need for assistance in self care Elder years (>80)

Nutrition Assessment Evaluation of collected information Prioritize nutritional problems

Nutrition Assessment Example 24 hour recall Guided interview to recall all foods and beverages consumed in past 24 hours (or typical day) Times, amounts, preparation methods Prompting

Responsibilities in Clinical Dietetics Nutrition Care Plan Based on diagnosis care plan for nutrition intervention i.e. special diet therapy, meal plan Includes plan for ongoing monitoring and evaluation (follow up) Monitoring Progress Follow-up on progress of plan to meet set goals Nutrient Analysis Evaluate nutritional content of foods consumed

Work time in Clinical Dietetics Average time involved in tasks 51% client-related activities 10% managerial functions 1% professional activities 5% non-professional activities 20% transit time

Nutrition Professional as Team Member Team approach Need integrated efforts to achieve desired outcomes No one can work entirely on their own

Advancement Opportunities Entry-level dietitian Specialization Team/Service Leader Clinical Nutrition Dept Manager

Future of Clinical Dietetics ↑ self-employed dietetic counselors ↓ out-patient services Client education changing venues timing ↑ need for long-term care ↑ employment by MD offices What other future outlooks do you think may occur?

Specialized Nutrition Support Enteral nutrition receiving nutrients via GI tract oral, tube, catheter, stoma Parenteral nutrition receiving nutrients via vein large, central OR smaller, peripheral

Goals of Health Care What are the two major goals of health care? Maximize human flourishing Curative medicine Minimize human suffering Palliative care care of the terminally ill aimed to improve quality of life

Reflection Comments How understanding may affect future practice? Sp/punc/gram/awk Terminology “eat healthy” “junk food” Proof read before submitting Spelling Dietitian Then vs. Than Desert vs. Dessert

Ethical Theories 3 ethical theories that affect attitudes towards health care delivery and services: Formalist Utilitarian Virtues 1. Ethical theories -- formalist -- deontological -- right and wrong -- black and white world with no middle ground -- utilitarian – consequentialist view -- weighs positive and negative -- works in the “grey” zone or in the middle ground -- Virtues -- perspective based on character of individual -- integrity, respect, compassion Bioethical Principles – over-riding principle – autonomy – justice – fairness to all people as equal in similar situation -- nonmaleficience – do no harm -- beneficence – doing good – choose action that will bring most good to patient

Bioethical Principles Autonomy Justice Nonmaleficience Beneficence REVIEW

Ethical Issues Is provision of nutrition morally obligatory or morally optional? Does this change with length of support? Do ethical guidelines differ for children, older adults, pregnant women, etc.? Morally optional -- nutrition alone can rarely restore consciousness – “futility of care” -- ultimate goal of any medical intervention should be improvement of prognosis, comfort, well-being or general health status Morally obligatory -- does withdrawal of nutrition/hydration appear to be intentional killing? Guidelines -- patient-centred treatment goals -- handle each case individually -- respect pt’s expressed desire for treatment or not -- consult with ethics committee for institution

Living Will or Advanced Health Directive Appoints individual to take over health care decisions Specific directives for course of treatment Terri Schiavo case (brain injury in mid 20s) Living wills still taken to court

Dietitian’s Roles Responsibilities of PDt/RD? What knowledge, skills, & attitudes needed for debate? sound technical judgment on a feeding strategy that meets desired goals Knowing what patients preference’s are Keep patient and family up to date and informed on outcomes of feeding Knowledge – disease physiology, moral reasoning, health care law, institutional policy Skills – situation analysis, critical thinking, facilitation, negotiation, communication, ethical decision making Attitude – empathy, patience, team approach, comfort with uncertainty, comfort with expressed anger

Required Readings Duester. (1997). Building your business – Setting your fees. Gross, & Ostrowski. (2008). Getting started in private practice.