Since the late 1980’s a new concept termed patient centered care emerged and has changed the way that patients are treated surrounding their healthcare, now prioritizing the patient’s individual needs, preferences, and values when making medical decisions and delivering treatment.

Patient centered care encourages the collaboration and partnered decision-making between the medical care team and the patient (and patient’s family,
if applicable). The primary goal of this model is to improve individual health outcomes by engaging patients as active participants in their own healthcare journey and focusing on the patient’s problem rather than their diagnosis.  By creating a broader view of the patient’s needs based on their individual body and experience, the healthcare team together with the patient can determine the right tools for the patient giving them more responsibility for their healthcare choices. Whether that be referrals for emotional, social, or economic needs or simply setting patients up on an online portal where they have access to schedule appointments, chat with medical professionals or review their chart notes and labs.  In a nutshell, patient centered care has created
a paradigm shift from patients being the “order takers” to becoming a “team member”.

At the heart of patient centered care is allowing patients to actively choose which care they receive by presenting patients with all evidence-based medical options for whatever issue they are dealing with. In fact, the American Medical Association’s code of Medical Ethics’ Opinions on Informing Patients state that “The physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good
medical practice”. 

Nutrition support in dialysis is a prime example of missed opportunities when it comes to involving the patient in their care and giving them all the options to work towards improved nutrition status. Up to 62% of hemodialysis patients and 50% of peritoneal dialysis patients are considered malnourished.  Malnutrition in the hemodialysis patient is generally characterized by albumin < 3.5 g/dL, weight loss of >5% in 3 months or >10% in 6 months, a nPCR
or nPNA of < 0.8 g/kg/d, an IBW< 90, a 7-point Subjective Global Assessment (SGA) score of 1-5, or a Malnutrition Inflammation Score (MIS) of 7-30.

The research and guidelines support a tiered approach of nutrition support while clinicians work to determine and resolve the underlying cause
of nutritional derangement. To improve nutrition status, the following can be considered:

  • First line treatments
    • Nutrition counseling from a registered dietitian
    • Oral nutrition supplements
  • Second line treatments:
    • Non-invasive – does not require additional access sites on increase patient burden
      • Intradialytic parenteral nutrition (IDPN) for hemodialysis
      • Intraperitoneal nutrition (IPN) for peritoneal dialysis
    • Invasive – requires placement of additional access sites
      • Enteral nutrition
      • Total parenteral nutrition
    • Pharmacologic – example, appetite stimulants

Having access to more than one treatment option is vital for ethical and effective patient care. Malnutrition is a strong predictor of impaired quality of life, infection, frailty, increased risk of hospitalization and increased risk of morbidity and mortality.

There have been many times in my different roles as a clinical registered dietitian where I’ve witnessed other medical professionals dictating care based on their own feelings about what options a patient should or should not be given. Some examples of statements I’ve heard from medical professionals include: “he’s too old”, “this patient isn’t compliant enough with…” or “this patient should just go to hospice”.  If we are truly following a patient centered model of care, none of these statements are okay nor ethical.

As clinicians who are rooted in evidence-based practice, we should feel called to stick up for our patients’ rights and specifically for our patients to be given the choice in care options. Past experiences or personal grievances should be countered with evidence-based recommendation for appropriate medical interventions. Being an advocate for your patients with your medical team ensures that every option is presented so that your patients have the best chance of making informed decisions that will affect them for the rest of their lives.

To learn more about diagnosing and treating malnutrition, please check out our available resources through our Clinician Portal:

    • 7-point SGA and MIS forms
    • 7-point SGA training video
    • Malnutrition Quick Facts
    • IDPN Quick Facts
    • IPN Quick Fact

We thank our guest blogger Sarah Voegtle, MS, RD, LDN, for sharing her knowledge and writing this blog post!