Pioneer Network’s New Dining Practice Standards support ADA’s Position on individualizing the elder’s diet. For practitioners, it’s time to let go . . .
Individualized, liberal diets are the foundation of The New Dining Practice Standards published by the Pioneer Network. And why not? Evidence based research continues to support therapeutic diets are detrimental at worst, neutral at best for the elderly.
This is a very difficult conversion for many practitioners to embrace. We support the concept, but when it comes down to actually individualizing the majority of diet orders to a less-restrictive diet (General) we flinch. Admit it, you as a practitioner are having a terrible time letting go of therapeutic diets for the resident with diabetes, cardiac disease, or chronic renal failure.
As with most things in our industry change is regulatory based. Pioneer Network in conjunction with CMS realized this and so the Food and Dining Clinical Standards Task Force was formed to take the documented positions of professional organizations and validate them via regulatory language. Three cheers for the visionaries.
Since it seems our every move is dictated by the regulations, take a look at them. This can be tedious for those of us that are not regulators, but it really is worth a look. The term individualize is sprinkled generously throughout the regulations. If you don’t believe me pull up the SOM Appendix pp on-line and search “individualize(d).” This knowledge should help bolster your cache of arguments for diet individualization.
Let’s examine current diet practices in the nursing home using the resident with CKD Stage 5 – dialysis. Our training and experience dictates this resident must be put on the renal diet we have standardized for our facility. For the sake of this example we will use a variation of an abbreviated renal diet of a General Diet, No Tomatoes, No Baked Potatoes, No Orange Juice, ½ cup Milk per day. Now every CKD Stage 5 Dialysis patient will have this diet order and will stay on this diet, regardless of serum potassium or phosphorous, because it is the standard diet of the facility. Where is the individualization that is mentioned in F325, “The care plan . . . identifies resident goals and choices and identifies resident specific interventions?” Going back to our example, how does the standard diet meet the needs of the resident with serum potassium of 3.2 mEq/L? It doesn’t, yet there are countless residents on dialysis receiving the standard renal diet of the facility. Diets are not being modified to meet individual needs and residents are not being allowed to make food choices.
Informed choice is a key phrase that is used throughout The New Dining Practice Standards and the OBRA regulations. As nutrition practitioners it becomes our duty to educate residents of the consequences (good and bad) of their choices then allow them to make choices. Most of our residents have been selecting the food they eat for at least 65 years, so why take that basic choice away? Some of you will argue their choices led them to the nursing home, but it is their right as citizens of the United States (F151 Exercise of Rights) to continue to make personal, informed choices about what they eat.
That leads us to the food from which the residents can select. During the course of our debates over the Standards I emphasized the need for personnel trained to cook. So often the food we serve is reheated canned or frozen foods. Lost is the art of the scratched-cooked meal. The use of Chefs trained in scratch cooking may enhance the flavor and nutritive value of food while reducing the excessive sodium, potassium, and fat often found in convenience foods. Plus the use of an a la carte menu offers a selection of foods from which the resident can make an informed choice. The RD working with the Chef in the development of menu choices supported by flavorful, healthful recipes is a win/win for the resident.
Individual, liberal diets will not appear in every nursing home overnight, but The New Dining Practice Standards will support their use via regulatory compliance (F281 Professional Standards). Embrace the change. Individualized diets will give our residents a little more control over their lives and may indirectly reduce the number of food complaints.