Development of the PEACE care pathway for dietetics

Development of PEACE care pathway for dietetics

Dietitians routinely worked with care pathways based on the BDA Process for Nutrition and Dietetic Care (BDA, 2012, 2016).  These were developed for specific treatment settings and diagnoses.  These templates are an element of clinical governance, providing a common language for good communication; standards for practice and audit; a basis for clinical supervision and for outcome measures.  Care pathways for eating disorders in in-patient, daycare and out-patient settings had been in use for some years.

The relevant pathways and associated documents were reviewed as part of the PEACE process, to seek making improvements for the care of individuals with and eating disorder and features of autism spectrum disorder.  As the PEACE process was implemented by the MDT, the dietitians involved considered each stage of the pathway, and made some modifications.

Assessment

The assessment template was amended to include seeking information that might be relevant to dietetic care in people with autistic features:

eating behaviour in early life, in particular food selectiveness or aversions, difficulty or distress associated with feeding 

sensory sensitivities relating to food

particular preferences relating to food presentation

self-imposed rules relating to food and eating

These prompts could then trigger further discussion of the difficulties, whether they should be a priority for treatment, and how they might be addressed in recovery from the eating disorder.

Dietetic Diagnosis

The assessment leads to identification of problems relating to nutrition and eating behaviour that might be addressed in dietetic treatment.  In eating disorders, these are most often related to:

• body weight, and body weight stability
• specific nutritional deficiencies related to inadequate intake of nutrient-rich foods
• unhealthy or unstable eating pattern
• binge eating
• risk of refeeding syndrome
• fluid intake

There may also be issues related to eating behaviour, for example avoidance of foods or food groups perceived as energy dense. 

If there are ASD-related features, there may be additional dietetic diagnoses, for example nutritional deficiency related to food avoidance due to sensory aversion or risk of choking.

The diagnoses are used to agree treatment aims and outcome measures.

Treatment

The style of thinking and learning of people with autistic features needs to be taken into account in planning treatment.There may be a need for a slower pace, with more therapist support, than in usual treatment programmes (Kinnaird et al, 2017).

Some aspects of eating behaviour, for example food avoidance because aversion to particular textures or flavours, might not be amenable to change, or need intensive support to change, so recovery would be planned to accommodate that, for example by using vitamin and mineral supplements or ONS rather than seeking increased variety of food intake.

Written materials are a useful reminder of information, but language and presentation need to be suitable for those with ASD features.  As part of the PEACE process, views of service users and carers, and information from the National Autistic Society and the Plain English Society websites, were used to produce guidance for dietitians to review materials already in use, and for producing further materials. 

Supervision

The needs of service users with ASD are routinely discussed in clinical supervision.

Huddles

The need for close collaboration among all members of the MDT is met with regular brief meetings (“huddles”).