Ethics and economics in nutritional support.

Enteral and parenteral nutritional support was developed to provide sustenance to patients who ordinarily were unable to meet their nutritional needs either because of an inability to eat or an inability to digest and absorb food. Undernutrition has been associated with increased infection risk, poor wound healing, increased postoperative complications, prolonged hospital stay, respiratory, cardiac, and hepatic dysfunction, as well as increased mortality. A clinical decision must be made about the provision of both nutrition as well as hydration fluids for patients otherwise able to eat in the usual fashion. Patients who had intestinal failure from either short bowel syndrome (congenital or acquired) or severe dysmotility disorders were doomed in the absence of parenteral nutrition. Soon after the advent of total parenteral nutrition (TPN) in the late 1960s and early 1970s, it was thought that TPN was the cure-all for many ills and it became integral to the management of the chemotherapy patient, bone marrow transplant patient, preoperative patient, burn patient, and trauma patient, among other patient subsets. It was once hypothesized that, because patients who received TPN had a significantly decreased serum cholesterol concentration, TPN might be a reasonable therapy for atherosclerotic heart disease [1]. As this therapy came under increasingly more widespread use, evidencebased medicine with regard to TPN began to evolve. It was found TPN did not increase the effectiveness of chemotherapy, improve bone marrow engraftment, result in decreased postoperative infections in only mildly or non-malnourished patients, and did not improve outcome in trauma (other than head trauma) or burn patients, and in fact was associated with significant treatment-related complications in some patients [2]. The survival rate Lochs H, Thomas DR (eds): Home Care Enteral Feeding. Nestlé Nutrition Workshop Series Clinical & Performance Program, vol 10, pp 143–166, Nestec Ltd., Vevey/S. Karger AG, Basel, © 2005.