Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study

Abstract

Background Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder. Aims To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings. Method People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants. Results Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, ‘quick decisions’, with the subthemes of ‘medical risk’, ‘impact of not eating’ and ‘limited discussions’; second, ‘slow decisions’, with subthemes of ‘threats’, ‘discussions with patient’, ‘not giving up’ and ‘advanced directives’. Benefits and harms of both quick and slow decisions were identified. Conclusions This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Nasogastric tube feeding under physical restraint of children and young people with mental disorders: a comprehensive audit and case series across paediatric wards in England

“…To our knowledge, this is the first national survey and case series of CYP receiving NGT feeding under restraint in English paediatric wards with the only similar previous research undertaken in mental health inpatient units in England 8 12 13. We found that around a third of paediatric units had provided NGT under restraint in the previous year.…”

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study

“…Research suggests that the best practice is advance care planning between patients, carers and the clinical team where there is a joint discussion and agreement regarding and potential use of restrictive practices and the conditions under which they might occur. 6 This should help individuals have a sense of ownership of the decision-making and understand that the clinicians are working with them from the start. This could become critical to success and collaboration if patients subsequently lose weight to the point of medical instability and clinicians need to consider overriding their wishes.…”

“…This could become critical to success and collaboration if patients subsequently lose weight to the point of medical instability and clinicians need to consider overriding their wishes. 21 , 24 , 25 Advance care planning can promote patient participation and prevent loss of agency when clinicians need to employ restrictive measures and help shift the narrative from ‘They are doing this to me, I didn't know this would happen, they just suddenly decided they would,’ to ‘This is my care plan, I did know this might happen and furthermore I do know why even if I can't agree.’ 6 …”

“…21,24,25 Advance care planning can promote patient participation and prevent loss of agency when clinicians need to employ restrictive measures and help shift the narrative from 'They are doing this to me, I didn't know this would happen, they just suddenly decided they would,' to 'This is my care plan, I did know this might happen and furthermore I do know why even if I can't agree.' 6 It is important to acknowledge two key issues that may complicate the ability of a clinical team to communicate with their patients. First, severe malnutrition can exacerbate neurocognitive deficits such as rigid thinking and reduce the ability for patients to understand, retain and weigh up the information they are being given i.e.…”

“… 5 In this paper, Neiderman and colleagues made nine suggestions for good practice which focused on the discussions prior to the intervention being needed, good communication, staff training and the need for constant reassessment of the need for the intervention. Our previous work examined the decision-making process of clinicians when this intervention is needed 6 and highlighted that patients have been diagnosed with post-traumatic stress disorder (PTSD) as a result of this intervention. 7 However, there is some practical guidance on how to amend traditional dietetic practice to ensure that when this intervention is needed, it is delivered as quickly and safely as possible, 8 , 9 and on clinical practice when this intervention is required on paediatric wards.…”