Patients' Experience of Nutrition Therapy During Critical Illness and Recovery A Narrative Review

Patients' Experience of Nutrition Therapy During Critical Illness and Recovery A Narrative Review

INTRODUCTION

Medical nutrition therapy is considered a mainstay of supportive treatment for the critically ill. This may encompass oral, enteral, and parenteral nutrition support.

Medical nutrition therapy has been associated with benefits during critical illness such as supporting the immune system, promoting gut integrity, and aiding wound healing. While many studies have investigated the route, amount, and timing of nutrition, patients' experience of nutrition during critical illness and recovery remains largely uninvestigated.

Clinical practice guidelines recommend that intubated patients commence medical nutrition therapy via enteral nutrition within twenty-four to forty-eight hours of intensive care unit admission. During this early phase, patients' awareness of medical interventions may be limited due to sedation, brain injury, or delirium, with decisions regarding nutrition directed by clinicians. As patients' conditions stabilize, their awareness of interventions will increase, and their experience of medical nutrition therapy becomes highly relevant to ongoing care.

In the intensive care unit, following the cessation of invasive mechanical ventilation, oral intake may commence. In the absence of ongoing brain illness or sedation, patients may be able to engage in decision-making about medical nutrition therapy by communicating individual preferences and challenges with nutrition; however, this has not been described in the literature. Following extubation, nutrition intake from oral diet alone has been described as well below clinician recommendations. Barriers affecting oral intake in the intensive care unit include symptoms which affect oral intake such as poor appetite, altered consciousness, nausea and many others (termed nutrition-impacting symptoms), issues with food service, and clinician-related factors. These experiences also affect patients who do not require intubation and can eat and drink throughout their intensive care unit admission.

Following transfer to the ward, ongoing medical nutrition therapy (including enteral nutrition or oral nutrition support) is often indicated as intake from oral diet frequently continues to be inadequate, with studies reporting thirty-seven percent to fifty-four percent of energy targets and forty-eight percent to sixty-five percent of protein targets achieved. Providing adequate nutrition for recovery can be challenging and must be balanced with patients' preferences. A lack of understanding by ward clinicians regarding nutritional needs in this patient group may contribute to this challenge.

Following hospital discharge to a rehabilitation setting or home, nutrition-impacting symptoms may last for months, affecting nutritional intake. However, little is known about the nutrition experiences of patients following discharge from acute-care hospital settings. After hospital discharge, patients may need to integrate medical nutrition therapy (most commonly oral nutrition support) into everyday life. Therefore, understanding patients' individual preferences and situations is imperative. It is also important to consider that eating and drinking is much more than simply consuming nutrients for the body, and can have complex cultural, emotional, and social implications.

In this narrative review, key aspects of the patient experience, and clinician and hospital-related factors influencing nutrition are summarized. Factors that both directly and indirectly impact the patient's experience of nutrition will be discussed.

DISCUSSION Patient Experiences of Enteral Nutrition Therapy

Nasogastric feeding tubes

For mechanically ventilated patients, the predominant form of nutrition is enteral nutrition delivered via a nasogastric tube, of which there are two main types. Larger polyvinyl-chloride tubes are termed "wide-bore" tubes and are relatively rigid. "Fine-bore" tubes are smaller, more pliable, and usually made of polyurethane. In the early stages of critical illness, when the risk of gastric and enteric dysfunction is high, wide-bore nasogastric tubes are commonly used for gastric drainage and checking of gastric residual volumes while also being used to administer enteral nutrition. Changing to a fine-bore tube may occur,

although when or if this happens varies widely. International critical care nutrition guidelines currently do not make recommendations regarding nasogastric tube type or size; however, it is plausible that the type of nasogastric tube could impact the patient experience. Furthermore, patients may have pre-existing preferences regarding tube feeding before becoming ill.

The patients' experience regarding nasogastric tubes is poorly described in patients with critical illness, although there are some reports of discomfort and distress. In a study investigating the experiences of intubated patients within the intensive care unit, nasogastric tube insertion was described by one patient as the hardest procedure to endure. Having a nasogastric tube has also been briefly described as being unpleasant or repulsive. In a study outside the intensive care unit context, the experiences of patients with malignant small bowel obstruction were explored. In this study, wide-bore nasogastric tubes were used for gastric decompression, one patient described the discomfort of the tube: "I hated that up my nose because it was so uncomfortable. It hurt me ... it was horrible and uncomfortable in my throat." There is some evidence that nasogastric tubes may impact swallowing function in healthy volunteers, though no clear differences between fine-bore and wide-bore tubes have been reported. Several authors describe fine-bore tubes as more comfortable for patients; however, no data are provided to substantiate these claims. Given a large number of critically ill patients experience nasogastric tube use, and it is at times an essential route for nutrition, this is an important gap in the literature and an area of patient experience that should be explored.