Authors (including presenting author) :
HO SKS1, NGAN C2, WONG CK1, LEE H3, CHU W1, SIN MY1, CHAN YK1, LI PY1, LUI P1, TSOI YS1, YUEN WM1, MAK PKF1, KNG PLC1
Affiliation :
1Department of Medicine and Geriatrics, RTSKH 2Department of Speech Therapy, RTSKH 3Department of Dietetic, RTSKH
Introduction :
Almost 85% of advanced dementia person experience feeding problems in last 18 months of life (1Mitchell S.et al., 2009) which commonly lead to nasogastric tube feeding. Careful hand feeding (CHF), based on HA’s guidelines2 provides an alternative option if patients or families refuse tube feeding. However, widespread adoption of CHF is impeded by practical or medico-legal concerns. To overcome this, we conduct practical implementation of complex feeding interventions.
Objectives :
Enhancing comfort feeding and pleasure in eating of patient at the end stage of life through empowerment of care givers on ethical principles and safe practice, which was facilitated by a multi-disciplinary team care pathway with staff and patient training toolkits.
Methodology :
A multi-disciplinary geriatrician-led “Feed team” was formed with specialist nurse, speech therapist and dietician. Roles and responsibilities were defined, ethical principles based on HA’s Guidelines and scope of CHF and target patients listed. A clinical guideline and care algorithm pathway was established with key elements (1) assessment for prognosis, reversible causes of dysphagia, decision-making capacity (2) communication with patient/families based on best interests using patient empowerment toolkits and within multidisciplinary team and with other HA teams through the CMS alert system (3) documentation in Advance Care Plan, informed consent for CHF by doctor and an individualized patient feeding plan by speech therapist. Other enablers were nurse training, flexible visiting and partnership with families, hydration round, use of condiments, food choices by dietician and follow up plans with community teams.
Result & Outcome :
The enhanced CHF program witnessed a tremendous rise from 14.3% (2016) to 100% (2020) for our team to support person-centred choice for CHF at end of life. Rate of nurses trained and willing to facilitate CHF increased from 33.3% to 92.3%. Further shortened duration of "nil by mouth" in geriatrics ward from 3.6 to 2.9 days. Food choice and condiments were supported by dietician and ward. Continuous improvement was based on frontline questionnaire feedback from 71 nurses conducted in September 2019. Majority (84.5%) agreed with the benefits of comfort care. For medico-legal concerns, 64.8% expressed the clinical guideline and informed consent could safeguard ward staff. However, difficulties in executing CHF remain, such as limited feeding time (47.9%), liability concerns (53.1%) and insufficient caregiver training (46.5%). 335 participants attended the CHF Forum with very good feedback. In conclusion, for complex feeding interventions, a concerted multidisciplinary co-produced care pathway is fundamental. Our CQI journey values frontline engagement and patient feedback for improving with a practical feeding plan, enhanced staff training, patient/carer educational toolkits and seamless care continuity into the community. All contribute to the enjoyment of "Free Feed" of our patient.
