All tube-fed people should be made aware that blended diet is a choice available to them. They need timely information so they can consider blended diet in their own circumstances. This decision should be supported by the healthcare professionals involved in the person’s care. This part covers what needs to be discussed as part of that decision-making process, and what a subsequent plan should record. This plan should be revisited as circumstances change.
1. Structure the conversation as a shared discussion
An individual risk assessment is not required and should not be a precondition. The decision must still be fully informed and documented. The conversation guide in Appendix 3 sets out the topics to cover, and Appendix 2 is written for the person and their family to take away.
2. The person’s own preferences, capacity and consent are central
Adults are presumed able to make their own decisions, including ones others consider unwise. Where an adult cannot, the decision is made under the mental capacity legislation applying in that nation, taking account of their wishes, feelings and beliefs. For children, it rests with those holding parental responsibility, weighting the child’s own views by their understanding. The person or people who will plan and prepare the blends should always be part of the discussion.
3. Discuss the different approaches to blended diet available
There are many ways to incorporate blended diet. The person or people preparing the blends should be aware of the different approaches available and be supported to make decisions about preparation methods. Appendix 1 sets out the approaches as a continuum.
4. Make one decision, shared across the MDT
A person should not have to remake the decision with each professional they see. Everyone involved should know what has been decided and their own role and responsibilities in relation to it. The feeding plan should be recorded and made available to every setting the person attends (Appendix 7).
5. Consider the type of enteral feeding tube used
Some tubes are better suited to blended diet than others. Blended diet is more commonly used with balloon retained gastrostomy tubes of 12Fr gauge or above. However, tube type and size alone should not preclude blended diet; there may be circumstances where another tube type is considered (Part 3).
6. Consider if additional ancillaries are required
Ancillary needs are unlikely to exceed those of the wider tube-fed population, but additional or O-ring syringes and containers can be helpful (Part 4).
7. Consider the time and cost involved
Blended diet takes time and work to plan, shop for, prepare and store. It also shifts the cost from the NHS to the tube-fed person’s household, since commercial enteral formula is prescribed. The costs and the support required can be set out in a Continuing Healthcare or Personal Health Budget application, for both children and adults, and the dietetic care plan should be included in it. Disability Living Allowance or its equivalent may be relevant. Some regional or condition-specific charities fund blenders.
8. Consider the equipment needed
The initial outlay on equipment can be a barrier for households on low incomes, so discuss it openly at the outset (Part 5).
9. Consider the current understanding of the person preparing the blends
This covers both nutrition (Part 6) and food safety and hygiene (Part 7). Where knowledge is lacking, what matters is a willingness to learn. Translating nutrition into practical terms is a core dietetic skill, and the dietitian can and should teach and support this.
10. Consider the person’s medical condition and any dietary requirements
A therapeutic or modified diet can be blended too, but it affects food choices and takes more planning and preparation, so specialist dietetic support is likely to be needed (Part 6).
11. Agree how the person will move onto a blended diet
Transition onto a blended diet may take several weeks, and it depends on feeding history as much as diagnosis (Part 8).
12. Agree how blended diet will be administered
Method, rate and posture all need to be agreed and recorded in the plan (Part 9).
13. Agree how blended diet will be monitored and when
A monitoring plan should be established, with parameters and review intervals agreed in advance and by whom. Agree with the person what is being monitored and why. Weight is almost always part of the plan, but the goal attached to it differs. The outcomes that matter to the tube-fed person, their family and carers belong in the plan alongside it (Part 10).
14. Identify where outside the home the person is fed
Tube-fed people are cared for in many settings other than their home, and provision outside the home can be a challenge. Consider whether the home or care setting, including paid carers, can support preparation. Settings may require support and training from enteral feeding professionals. Many people also manage to work or travel with a tube and blended diet (Part 11).
15. Plan ahead for transitions
Transition means any change in circumstance, treatment or setting and is applicable to children and adults (Part 12).
16. Support the decision not to use blended diet, or to stop
Some people decide that blended diet is too difficult under their circumstances. The level of work required should not be underestimated. No one should be made to feel guilty for deciding not to try blended diet, or to stop. Some may choose to use blended diet only on special occasions, where sharing food with others matters most to them.