Adult services are encountering blended diet by two routes.
Firstly, inheriting people established on it for years who transition from children’s services.
Secondly, requests from adults who begin tube feeding later in life, particularly in motor neurone disease and in head and neck and upper gastrointestinal cancer.
This part covers both instances, and the planned transfer between paediatric and adult services, which should begin years before it happens.
It is the first edition to address adults directly.
1. Offer blended diet as one of the options
Blended diet may not suit every adult. Make the decision with the individual, based on assessment and clinical judgement as set out in Part 2.
Take account of the person’s goals and quality-of-life priorities, the availability and capability of carers, and whether the home or care environment can support it.
Consider when to start, and practical guidance on how to administer should be discussed directly with the individual.
Where a person depends on paid carers, the arrangement depends on the provider as much as on the person, so agree the care plan before starting.
Where paid care is needed, agree the arrangement through the multidisciplinary team, and include the dietetic care plan in any application for funding, such as NHS Continuing Healthcare (Part 2).
Where an adult cannot make the decision themselves, follow the mental capacity legislation applying in that nation (Part 2).
2. Raise it before gastrostomy insertion in progressive conditions
Discussing blended diet early, particularly in progressive neurological conditions, may improve acceptance of enteral feeding and help the person make an informed decision.
Adults with motor neurone disease have described preferring blended diet because it fits their values and lifestyle.
Knowing it is possible can change how a person feels about a gastrostomy placement.
3. The same principles apply in residential and supported living
The learning from settings that already provide blended diet in education, respite and hospital applies equally to residential and supported living in adult care (Part 11).
Working UK models exist, including a residential service where catering staff cook and blend, and a hospice batch blending in advance.
The principles are the same throughout: agreed procedures, trained staff, and a documented alternative.
4. Assess competency on the tube feeding task, not on the blend
Roundtable participants favoured training and support over formal competency assessment systems.
Where a setting uses competency assessment, it covers giving an enteral feed through the tube and caring for the tube and stoma as a delegated healthcare task.
There is no separate blended diet competency to assess, because ingredients and consistency vary from meal to meal, and a sign-off would only be a snapshot.
Check what the care provider’s contract already covers. Where it includes giving an enteral feed as a delegated healthcare task, giving a blend falls within it, which helps to normalise blended diet for staff.
Tolerance and consistency are better picked up in training alongside the person who prepares and gives the blend at home (Part 11).
5. Start transition planning early, from around fourteen
Most paediatric services begin transition planning at about fourteen, though this varies with the primary condition and locality.
Each trust or health board has a transition policy setting out how the transfer is coordinated.
Check that it covers dietetic care, including how home enteral feeding is handed over.
Start early and plan the transfer of the feeding plan with the whole team, including the GP, the young person and their family or carers.
Link it to the other transition plans already in place for them.
Engage the receiving service early, hold joint reviews with both teams, and arrange for receiving staff to attend blended diet training and observe preparation and administration.
Care plans, monitoring information and training records should transfer with the person.
6. Write dietetic transition guidance with your adult colleagues
Guidance written jointly by the children’s and adult dietetic services, covering how home enteral feeding is handed over, keeps the transfer consistent.
Establish what training and support the enteral feeding contract provides in the adult service.
Check whether equipment will change, since the adult service may use a different enteral supply contract, with different syringes, extension sets or pumps (Part 4).
Nurse provision built into the contract differs between areas, and the family will want to know what carries across.
7. Accept established users without reassessment
When a young person transferring to adult services has followed a blended diet for many years and is established and stable, the decision is long made, so care and feed should not change without a clear reason.
Continue it and review it as you would any other established feeding plan, looking at tolerance, the ability to administer blends and nutritional status.
Check whether nutritional requirements are being met and, where they are not, the clinical impact.
Where adult teams are reluctant, this is usually unfamiliarity, not opposition.
Joint visits, shared caseloads and mirrored guidance have all helped.
8. Plan for the change in decision-making at 18
At 18 the legal basis of the decision changes even where the person’s capacity has not. Parental responsibility ends and decisions are made under the mental capacity legislation applying in that nation, with a best interests process where the person cannot decide for themselves.
Plan this in advance of the transfer, since the adult care package, respite and care settings may decline to administer a non-prescribed feed the person does not have capacity to consent to.
The care setting may not have access to training required to meet the competency requirement to fulfil the delegated healthcare task.
Parents remain central to that process, and to the day-to-day work of preparing blends and the method of delivery.
9. Agree what happens on an adult hospital admission
Plan the first adult admission before it happens, with the feeding plan agreed and recorded.
An enteral tube feed passport, carried by the person, is used in some services to set out the tube, the feeding plan and who to contact, and it saves the person explaining blended diet from scratch on a ward that has not met them.
Name the adult healthcare professional to approach for problems with the tube or stoma site (Part 11).
Appendix 9 sets out the steps to take on admission.
Participants of roundtable 4 recognised the benefits of introducing discussions about blended diet early within the patient journey, particularly for people with progressive neurological conditions.
It highlighted to me the difference between a reactive and a proactive approach to this.