Abstract
The issue of undernutrition in today’s world is applicable to many settings throughout society. The prevalence of this issue does not seem to be decreasing despite the many medical advances in this area in the 21st century and there does not seem to be as much significance on this issue despite its importance in clinical care. Therefore, this essay will investigate the nutritional care of malnourished patients in today’s society and will examine why despite the increase in emphasis being put on human rights in general, nutritional care does not seem to be discussed as significantly as a human rights issue.
Introduction
Malnutrition is defined as ‘a state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue/body form and function and clinical outcome’. (1) According to the World Health Organisation (WHO), the term malnutrition covers 2 groups of conditions. Firstly, undernutrition which includes ‘stunting, wasting, underweight and micronutrient deficiencies or insufficiencies.’ (2) It also covers ‘overweight, obesity and diet-related noncommunicable diseases such as heart disease, stroke, diabetes, and cancer.’ (2) Although both are thought to have a great impact on the health of many patients and require individual treatment plans, we will be focusing on whether the treatment of undernutrition in patients is a human right.
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The prevalence of undernutrition in the UK was highlighted in a 2019 British Association for Parenteral and Enteral Nutrition (BAPEN) survey, stating that in terms of malnutrition risk, using the Malnutrition Universal Screening Tool (MUST), ‘42% of individuals in the survey were at medium or high risk of malnutrition while just over half were at low risk of malnutrition.’ (3) Furthermore, patients who were at risk of malnutrition were found in ‘similar quantities’ in hospitals, care homes and at home but were ‘slightly higher’ in community rehab/hospitals and lowest in mental health units. (3) This emphasizes the importance of nutritional care for undernourished patients at all levels of care across the community and opens discussion into how these patients’ human rights in relation to nutritional care are affected in different care settings.
With the increasing prevalence of undernourished patients in hospital and care settings, it emphasizes the importance of nutritional care of malnourished patients as a priority for healthcare providers. Furthermore, the increasing issue of the increase of undernourished patients needing nutritional care raises the question of whether or not this treatment of malnourished patients should be a human right.
Human Rights of Patients
Human Rights are defined by the Equality and Human Rights Commission as ‘the basic rights and freedoms that belong to every person in the world, from birth until death.’ (4) Human rights in patient care are said to ‘bring together both the rights of the patients and health care providers and refers to the application of general human rights principles to the context of patient care.’ (5) In Inpatient care it is necessary to recognize the rights and dignity of the patient and to ensure their treatment or lack of treatment is not denying them their human rights. The nutritional care of undernourished patients is just as important, although it may not be prioritized by caregivers due to the lack of policies and legislation on the importance of nutritional care of malnourished patients.
One of the major instances of this currently is the lack of nutritional care and hospital malnourishment-related goals in the United Nations Sustainable Development Goals. (6) Despite the 17 goals and 169 targets the goals fail to mention any nutritional care targets or disease-related malnutrition goals which are both increasing issues as shown by the increasing prevalence of undernourishment in the community and primary care settings. (3) In fact, it is highlighted by a 2019 study (7) that goal 2 ‘Zero Hunger’ and goal 3 ‘Good Health and Well-being’ both completely neglect to mention either disease-related malnutrition or increasing nutritional care education which is necessary to prevent malnutrition globally. Furthermore, target 2.2 states that they aim to ‘By 2020 end all forms of malnutrition (6) which would be impossible to accomplish without also considering disease-related malnutrition, malnutrition in primary and community care and nutritional care policies. This calls us to question whether the nutritional care of malnourished patients should be of a higher priority with policies in place to protect these patients and their human rights, and may suggest to us that currently the nutritional care of malnourished patients is not considered widely as a human right and more emphasis needs to be put on this issue.
If malnourished patients are not receiving proper nutritional care, and this lack of treatment is putting their health and dignity at risk, this may suggest that there is a violation of their rights. The World Health Organisation (WHO) Constitution envisages “…the highest attainable standard of health as a fundamental right of every human being.” (8) This helps support the idea that the treatment of malnourished patients is a human right as the treatment of these patients is necessary in order to maintain health, let alone a high standard of health for these patients. Therefore, this suggests there is a need for more attention to the issue of nutritional care of the malnourished across healthcare, and for the necessary resources, education, and legislation to be put in place by the government to ensure their dignity and respect is maintained and every patient is treated equally, so as to ensure their rights are not violated.
Causes of malnutrition
When considering the nutritional care of malnourish patients as a human right issue, it is important to explore the causes of undernutrition and barriers to the nutritional care of these patients which may be infringing on their human rights. Firstly, one major cause of undernutrition in the UK is disease-related malnutrition. Some long-term conditions such as ‘cancer, liver disease and lung conditions that cause loss of appetite, nausea, vomiting and bowel problems (9), can result in malnutrition and lead to these patients being hospitalized if they were not already. Mental health conditions can also cause undernutrition as they can affect mood and desire to eat. In fact, a study (9) of community-living elderly men and women found that ‘impaired mental health was strongly associated with the risk of malnutrition.’ (10) Other causes of undernutrition include but are not limited to dementia, Crohn’s disease, ulcerative colitis, and eating disorders. (9)
Physical and social factors can also greatly contribute to malnutrition, for example, ‘dentures that make it difficult to eat, physical disabilities which make it difficult to make food or shop, social isolation, alcohol or drug dependency, low income or having limited knowledge on cooking and/or nutrition. (9) These are just some of the many causes of malnutrition in both the community and primary care settings. With so many causes linked to many different demographics of people, it once again highlights the overbearing need for nutritional care for many patients and supports the suggestion that nutritional care for patients with malnourishment should be a human right, as it is a common problem across the care system.
Barriers to treatment of malnutrition
When considering that the treatment of malnourished patients may be a human right, it is important to also consider the barriers to the nutritional care of these patients, that may be denying them these human rights. It is also important to discuss inequalities that malnourished patients may also experience due to these barriers, as this encourages the idea that nutritional care should be a human right in order for every patient to receive equal care. In a report (11) on behalf of the British Association for Parenteral and Enteral Nutrition (BAPEN), patients, families and carers were asked about their experiences with nutritional care and were given a chance to express their opinions and concerns. In this report, many barriers to proper nutritional care were identified. For example, when patients were asked if they experience inequalities in the nutrition services they receive due to ‘location, lack of attention to ethnic, religious or cultural differences, communication or language difficulties and lastly disabilities such as mobility or flexibility issues affecting treatment options,’ most responded with ‘usually’ or ‘sometimes’. (11) These inequalities in providing nutritional care suggest there may be a lack of resources, training, and experience of staff when treating these patients, which is worrying considering that providing nutritional care to these patients is essential for their health. This was a very insightful report as it included real patient involvement which is very important when considering nutritional care as a human right as a patient is likely to be the most perceptive to when their rights are being violated and will have the best understanding of what standard of care should be considered a human right as each individual will have their own beliefs of what standard of care is necessary to maintain their dignity and respect.
In addition, a study(12) carried out to identify what nurses experience as barriers to ensuring adequate nutritional care for the undernourished hospitalized elderly, also highlighted that many patients are not receiving a sufficient level of nutritional care across the healthcare system. This study (12) highlighted 5 themes that reflect barriers the nurse experience- ‘loneliness in nutritional care, a need for competence in nutritional care, low flexibility in food service practices, system failure in nutritional care and lastly nutritional care being ignored. (12) These barriers reveal that important elements in nutritional care are missing in clinical practice, despite the fact, several of the recommendations are in the national guidelines. This again emphasizes that although every patient has a basic human right to have their healthcare needs met, and therefore nutritional needs met, these fundamental needs are not being achieved.
Defining Nutritional Care
If the nutritional care of malnourished patients is to be considered a human right it is also important to clarify what nutritional care is necessary for these patients to maintain the ‘highest attainable standard of health’ (8). The National Institute for Health Care and Excellence(NICE) guidelines(13) are clear on their advice for the treatment of adult patients with malnourishment or at risk of malnourishment in hospitals, care homes or at home. They clearly state that nutritional support should be considered for patients who are malnourished which is defined by falling under one of the following criteria, a BMI of less than 18.5 kg/m2; unintentional weight loss greater than 10% within the last 3–6 months; a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.’ (13) This criteria highlights the standard procedure for classifying patients who need nutritional care as basic supportive care to maintain their health.
Once the healthcare team has assessed the patient's needs and has attained that they need nutritional care the patient will most likely be offered oral, enteral, or parenteral support. Examples of oral nutritional support is ‘fortified food, additional snacks and/or sip feeds’ (13). Enteral feeding is ‘the delivery of a nutritionally complete feed directly into the gut via a tube’ while parenteral feeding is ‘the delivery of nutrition intravenously.’ (13) Although these methods have been shown to improve outcomes, the decisions on the most effective and safe treatment is complex and must be discussed with the patient's complete medical team. Furthermore, the NICE guidelines (13) also highlight that it is not always appropriate to provide nutritional support and it may be ‘more suitable to withhold or withdraw this treatment.’ (13)
Therefore, although some may argue that in line with a patient's right to health’, which is defined by the United Nations as ‘The right to the enjoyment of the highest attainable standard of physical and mental health (14) every patient should be offered nutritional care to treat malnourishment in order to fulfill their human rights, this may not always be the best treatment plan for them. Every individual patient’s healthcare team will be working in the best interests of their patient, and therefore may feel its best to withhold or withdraw treatment that is compliant with the patient's human rights to achieve the ‘highest attainable standard of physical and mental health.’ (14)
Different patient's nutritional care
When looking at the human rights of malnourished patients, it is also important to look at how different demographics are affected individually. For example, geriatric patients are a group that are usually at ‘a higher risk of malnutrition and will more commonly have poorer outcomes. (15) In fact, a study (16) identifying malnutrition in the elderly found that of 10,000 elderly people, malnutrition was present in ‘1% of community-healthy elderly persons, 4% in outpatients receiving home care, 5% in patients with Alzheimer's disease living at home, 20% in hospitalized patients, and 37% in institutionalized elderly persons.’ (16) With this high prevalence of malnutrition especially in hospitalized and institutionalized elderly persons, it may suggest there is some neglect in the treatment of their malnutrition and raises the question of whether their human rights to health is being violated.
Age discrimination is defined as, ‘when someone is treated differently, with an unreasonable or disproportionate impact, simply because of their age’ (17) and is a direct violation of their rights. This suggests that elderly patients with malnourishment may be more likely to have their human rights violated due to the ‘higher prevalence of poorer outcomes’ (15) in these patients which put their right to health at risk. This encourages the importance of more emphasis on nutritional care for malnourished patients as a human right, so as to ensure each patient is treated equally to achieve the ‘highest attainable standard of physical and mental health. (14)
Effectiveness of nutritional care
The nutritional care of malnourished patients traditionally involves oral, enteral, and parenteral feeding. If these types of treatments are to be considered as a human right for malnourished patients it is also important to ensure their efficacy and effectiveness of them and explore any other treatment options that may be effective. To encourage the proper following of guidelines and standardized education of healthcare staff clarification of the most appropriate treatments for each individual patient is necessary. For example, in a 2018 study (18) on the effectiveness of nutritional interventions in older adults at risk of malnutrition it was found that ‘oral nutritional support is effective in increasing energy intake and body weight. (18) However, on the contrary, it was also found that dietary counseling with or without oral nutritional support was more effective compared to oral nutritional support alone. (18)
Similarly, a study (19) explored the effectiveness of supportive interventions such as ‘changes to the organization of nutritional care, changes to the feeding environment, modification of meal profile or pattern, additional supplementation of meals, congregate and home meal delivery systems, in enhancing dietary intake in malnourished or nutritionally at-risk adults. (19) This study found that it is possible that supportive interventions can reduce death from any cause as there were ‘approximately 23 fewer cases of death per 1000 participants in favor of supportive interventions’ (19). However, there needs to be further investigation to support this as the overall quality of evidence for this study were between moderate and low, and therefore may not be as reliable as the aforementioned study with the risk of bias also uncertain.
On the other hand, the 2018 study (18) seems to be very reliable, as it included an analysis of nine randomized control trials, which should support the idea that extra supportive measures such as the dietary counseling mentioned in this study are effective in treating malnourished patients. This poses the problem of what parts of nutritional care are to be valued as a human right. If all these measures can be effective in different ways to each individual patient it may suggest there needs to be more education on the value of not only traditional routes of nutritional care but also these supportive measures as their efficacy in treating the undernourished needs to be valued and should also be viewed as a human right to every patient.
Ethics of nutritional care as a human right
When looking at the human rights of patients it is also important to keep in mind the four pillars of medical ethics, which the members of a patient’s multidisciplinary team should uphold at all times. Recognizing that as a human right every undernourished patient should have the same access to the same nutritional care is also an important aspect of this. Justice, one of the pillars of medical ethics, highlights how each patient should be treated ‘equally and fairly when being offered treatment’. (20) In the context of the treatment of undernourished patients, this highlights how every patient should have an equal chance of receiving the same standard of treatment for undernourishment throughout the world.
The treatment of malnourishment posed as a human right is also supported by the human right to food which is similarly linked to the right to health. According to the Office of the High Commissioner for Human Rights, ‘Human rights are interdependent, indivisible and interrelated.’ (21) Therefore, nutritional care of the undernourished is a component of both the right to health and the right to food and can also be seen as a human right by itself. (21) Furthermore, violating the right to the nutritional care of malnourished patients may subsequently also inhibit other human rights such as the right to health and food, and vice versa. (7)
All healthcare professionals work with the best interests of their patients in mind. This relates to two other pillars of medical ethics, beneficence, and non-maleficence. These encase two of the oldest guidelines in medicine- ‘to do good and avoid harm.’ (21) This again encompasses the idea of knowing when is best to give the patient the necessary treatment or when it is best to withhold nutritional care. This can be a sensitive topic as decisions that involve the withholding or withdrawing of nutrition support require a consideration of both ethical and legal principles. (22)
The autonomy of the patient and their competency to make their own decisions for their health must also be carefully considered in order to ensure their human right to nutritional care is not being violated and nutritional care is still valued as a treatment option. It is a general legal and ethical principle that valid consent must be obtained before starting treatment for a patient(22), and any violation of this can result in the patient's human rights being violated and legal repercussions for the medical professional involved. Discussion of a patient's rights and capacity to make decisions is very important, especially in situations such as palliative care, where withholding nutritional care may be in the best interest of the patient, not just in the case of their medical care but also in taking a holistic approach in treating the patient’s needs.
Current initiatives on nutritional care as a human right
Acknowledging the value of nutritional care as a treatment for patients with malnourishment supports nutritional care being recognized as a human right. Subsequently, in the last decade, there have been some new initiatives and campaigns to help raise awareness of the importance of nutritional care for undernourished patients and to increase understanding of the importance of all patients being offered the same opportunity to these treatments. For example, in 2014 a campaign called Optimal Nutritional Care for All (ONCA) was launched as an initiative to ‘facilitate greater screening for risk of disease-related malnutrition/undernutrition and nutritional care implementation across Europe.’ (23) The European Nutrition for Health Alliance worked extensively to get disease-related malnutrition and undernutrition on the European health agenda and subsequently the ONCA campaign collaborates with many countries across Europe to ensure optimal nutritional care is implemented for all in keeping with patients’ human rights.
In addition, the James Lind Alliance (JLA) (24) is another non-profit which has initiatives established to combat undernutrition. It brings together patients, carers and clinicians in ‘Priority Setting Partnerships (PSPs)’, to identify the top 10 most important unanswered questions or evidence uncertainties in many areas. Nutritional screening and malnutrition PSPs were added to this list in 2019, and include up to 26 questions that are seen as priorities in order to combat malnutrition and educate on the best standard of nutrition they can achieve. (24) Many of these questions include issues that involve the patient opinion of malnutrition, which is an important topic of discussion if undernutrition is to be prevented.
Consequently, this raised awareness of nutritional care highlights how nutritional care of malnourished patients is becoming more valued in both clinical opinion and public opinion, as these views are essential if nutritional care of malnourished patients is to be appreciated as a human right for all patients. The nutritional care of malnourished patients is a multidimensional problem that leads to many challenges throughout all sectors of the healthcare system in finding interventions and policies that work in the best interest of all patients. (25) This means if it is to be ensured the nutritional care of malnourished patients remains at the forefront of human rights issues, multisectoral approaches are needed to ensure legislation is put in place to protect all patients’ rights equally in relation to the treatment of their malnourishment. Therefore it may be advised that when considering the treatment of malnutrition a human rights-based approach(HRBA) (26) is ensured as the framework on which nutritional care plans are based so as to ensure the human rights of patients are protected when developing new standards and practices to implement to prevent malnutrition.
Conclusion
Malnutrition is still a widespread issue in today’s society among all age groups and demographics of patients, highlighted by the widespread causes of malnutrition. Despite this, it is clear that there is not as much legal, clinical and ethical discussion around this topic as there should be when considering the prevalence of undernourishment in the population.
Bibliography
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