June Summary

The posts to most of these questions emphasized the importance of further research, patient-focused care when determining needs, and even questioning new approaches to feeding due to unfamiliarity. Although it is important to consider the patient’s individual needs, first and foremost, and look at a range of high-quality research, it is also crucial to realize the downfall of following standard feedings procedures simply because it is seen as a time-honored practice. What we once thought was the best answer possible may inevitably change once new light is shed on alternative answers. While further research must be conducted on the specific effect of parenteral nutrition on various disease states, this poses somewhat of a problem in that it would require participation from a large amount of patients who may or may not have other underlying conditions. That is, however, the reality in which there are no perfectly closed systems for straight comparison between group A and group B and it is the job of the researcher to take these unavoidable factors into account. In terms of ethical issues, which is often a subject of debate when dealing with human research, the article brings up a valid point in those who may find it unethical to withhold parenteral nutrition: it is, rather, unethical to provide a therapy that is actually unproven and potentially dangerous given all the research presented in this meta-analysis.

The article provides detailed information on the efficacy of either therapy for patients of specific disease states. Studies on the effect of parenteral nutrition versus protein-sparing therapy in the critically ill, acute pancreatitis, liver disease, inflammatory bowel disease, oncologic therapy, AIDS, pulmonary disease, renal failure, low birth weight infants, home parenteral nutrition, and perioperative patients were all reviewed. With the exception of upper GI cancer patients who received preoperative parenteral nutrition and, as a result, had fewer major complications (although it is important to note this was one of the low-quality trials I mentioned previously), the other studies were either inconclusive (patients with acute pancreatitis and bone marrow transplants) or found that parenteral nutrition was either not beneficial or had inadequate data to provide a strong conclusion. The clinical conditions in which there were no or inadequate randomized controlled trials are undoubtedly the areas that require further exploration. The conditions in which there was no benefit seen in providing parenteral nutrition should also be studied further to either reinforce or dispute the current conclusions. If these patients truly do not benefit from receiving parenteral nutrition, this therapy would ultimately be deemed an unnecessary treatment that instead may negatively impact the patient by causing them to endure unnecessary placement of feeding tubes and perhaps even length of stay in some cases, as evidenced by one of the additional articles.

It is our job as a dietitian, working in conjunction with the rest of the medical staff, to assess a patient by considering all factors—the lab values, disease state, past medical history, eating habits, and so forth. We should also consider not only what standard calculations and protocols we learned over the course of our education, but also the expertise of each individual in a multidisciplinary team as well as recent research and realize that what we learned about the “textbook patient” may not always fit the needs of the “real-life patient”.