1. Clinical Practice: Acute & Chronic Care

2. 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 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

3. 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

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

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

6. 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)

7. Nutrition Assessment Evaluation of collected information
Prioritize nutritional problems

8. 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

9. 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

10. 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

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

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

13. 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?

14. 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

15. 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

16. 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

17. 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

18. Bioethical Principles
Autonomy
Justice
Nonmaleficience
Beneficence
REVIEW

19. 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

20. 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

21. 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

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