"I am not an ideologue, but I just can't eat raspberry Jell-O again." "I'm vegetarian. That includes Salisbury steak." "Por cuarenta años, comía comida mexicana, muy tradicional. ¿Y ahora, me quiere que comer esta comida? No me digas!" From my first day in the hospital, I realized that the quickest way to build rapport with patients was to ask them what they thought of the food. They had many reasons for not liking it. For many older women, some who even eschewed restaurants their whole lives, just not being able to cook familiar items for themselves was the loss. More urbane patients compared the hospital food unfavorably with finer trattorie. And some were unhappy that they were forced to follow dietary recommendations that they ignored at home.
But in listening to these patients bemoan the cuisine, launching reflexively into silently rehearsed monologues composed during oddly solitary meals, I realized that invariably they were using the food as a point of entry to a more existential complaint -- a complaint that reflects a deep structural problem in the American hospital experience. Patients in hospitals have illnesses that require specific treatments. And hospitals are well positioned to provide this targeted care. However, many hospitals perform this fundamental mission in a relatively alienating, dehumanizing environment. Hospitals cannot make illness an enjoyable experience: Patients are often incapacitated or in pain, and many are forced to confront their mortality in ways in which they have not previously. But ideally, the hospital infrastructure would aid patients through these struggles, or at least avoid contributing to patients' general sense of illness. From being woken up before dawn to a prerounding medical student's prods to the sterile, institutional environment -- with its incessant beeps, lack of privacy, and endless parades of uniformed strangers -- it seems that the structure of the hospitals is not conducive to optimal health. The suboptimal nature of the hospital structure has not been entirely overlooked; the design of some newer hospitals, especially women's and children's facilities, includes natural light, soothing views, and larger waiting areas. Furthermore, there is mounting evidence that these changes are actually cost-effective.[1] However, in older facilities where the traditional hospital foundation remains untouched, doctors and nurses are routinely lauded for overcoming the structural limitations of the hospital in attending to patients with compassion. But the question remains: Why must so many healthcare professionals swim against the tide in caring for the whole person in the hospital bed? Why can't the infrastructure of more hospitals support this mission?
In medicine today, the growing integrative and alternative medicine movement has struck a chord with a public disillusioned with treatment of chronic disease that is reactive and symptom-based.[2] Public health dogma has fueled the fire of integrative medicine by emphasizing that most of the gains to be made in reducing morbidity from chronic disease lie in prevention rather than acute treatment. For many people, the integrative medicine approach to disease provides a method, chiefly in an outpatient setting, to slow the progression of diabetes or make the lifestyle changes necessary to prevent the onset of disease. However, leaders of this movement go out of their way to argue that the traditional allopathic model has more utility than the integrative model in the treatment of acute illness. Rudolph Ballentine[3] states in Radical Healing that "natural remedies can sometimes be quite effective . . . even addressing deeper emotional causes, but in dire circumstances it may well be more prudent to use conventional medicine for the moment." Andrew Weil[4] writes, "If I were a victim of a major automobile accident, I would want to be taken to a modern hospital emergency room, not to a homeopath, shaman, herbalist, or chiropractor." Does integrative medicine, then, have no place in the tertiary care hospitals where most of us complete our training?
I am not bold enough to disagree with their statements in principle. However, I do take issue with the implicit notion that because trauma centers provide excellent trauma care, they are immune from critique of their lack of holism. Ken Pelletier[5] claims that inherent in holistic medicine is "a recognition that each state of health and disease requires a consideration of all contributing factors," and he is explicit that this perspective is not antagonistic to traditional medical treatment. A holistic model has usefulness at every juncture in the healthcare delivery system. The management of severe burns exemplifies the utility of a holistic approach to care. Nutritional assessment is required to account for the increased metabolic rate and the increased need for specific micronutrients, which may include omega-3 fatty acids, zinc, and vitamin C.[6] Although often overlooked, adequate psychological care may foster healing, as patients with comorbid psychiatric conditions are overrepresented in burn units and can have poorer outcomes.[7] Finally, specialized pain management is essential because poorly managed pain can impair wound healing.[8] More and more, practitioners are providing care with this patient-centered, integrative approach in mind. However, in the absence of a hospital environment supportive of the holistic mission, practitioners' best intentions are often futile. Make no mistake: It is a daunting mission to change the structure of an entrenched, and invariably financially strapped, institution. However, it seems that hospital meals, which will remain a thrice-daily component of hospital life whether they taste good or not, are a reasonable place to begin reform without turning the hospital infrastructure upside down.
Here are the several recommendations for change, ways that we can take action to make the hospital more in keeping with its stated mission to promote the healing of individuals with illness.
First, patients should have access to a variety of fresh foods on their schedules. Diets that are nutritionally adequate may not be emotionally adequate, often resulting in a progressive decline in nutritional status during hospitalization that is in part independent of disease.[9] Although patients are offered sufficient calories to maintain weight, food wastage in hospitals is in excess of 40%, with the implication being that patients are only consuming 60% of their caloric needs.[10] When patients lose weight or are malnourished, health outcomes decline and morbid events increase[11]; the weight loss that occurs during hospitalization is an important contributor to this phenomenon.[12] Although certain morbidities are predicated solely on poor fundamental health status prior to admission, the hospital should do everything that it can to minimize decline in nutritional status during hospitalization by increasing access to snacks and familiar foods, as well as improving overall taste and quality.
Second, patients, their families, and healthcare providers (should they be so inclined) should share communal mealtimes. For most people, food is an inherently social activity. Outside of the hospital setting, many patients do not eat meals alone, in silence or watching television. Even for those who do eat alone at home, mealtime offers a powerful opportunity to foster communication and connection among patients and their families. There are, of course, numerous patients, including those who are intubated, immunocompromised, or otherwise immobile, for whom this is unfeasible. Many individuals may not want to take part, and this of course should be their prerogative. However, many people would benefit greatly from sharing meals with other patients, as well as with members of their healthcare team. Many long-term care facilities have a common room where fruit and drinks are continuously available and residents can bring their meal trays. Many hospital floors have a space that could serve this purpose. The hospital as an institution should help facilitate, rather than discourage, socializing among patients by making certain rooms available for communal meals.
Third, family and friends of patients should be able to spend more quality time in the hospital. A recent movement has successfully increased visiting hours in many intensive care units (ICUs),[13] which has been received well by both families and staff. However, facilitating a meaningful visitation experience for family requires more than access to the bedside. One important way that this can be achieved is through increasing the involvement of family in the nursing care, most notably by providing food. In much of the developing world, nursing care and food are provided by family members who often stay in the room with the patients. Most American families probably do not have the means or desire to follow the lead of the developing world in this case. However, providing family members with meaningful tasks can make them more involved in care. One important way that this can happen is by allowing them to provide nutrition to the patient, supervised by nursing staff. This allows the patient to eat traditional, familiar, and appealing foods, reducing the likelihood of progressive malnutrition during hospitalization. It can also provide a reduction in stress for both the patient and the family by allowing family members to feel less detached and out of control regarding a family member's care.
Alterations of hospital protocol toward realizing these changes will be met with resistance, based on initial costs, perceptions of increased workload for healthcare workers, and fear of upsetting the status quo. However, if we accept that being surrounded by loving family, familiar and healthful food, and a healthcare team and other patients who are seen as individuals can result in more satisfying hospital experiences and, perhaps, better health outcomes, then we have the responsibility to push for systemic changes in the hospital environment that will make these goals achievable. The only risk is that a patient might not have anything to complain about, and the third-year medical student would have to find other ways to engage him/her to solicit trust in the process of healing.
© 2005 Medscape
Cite this: The Healing Potential of Hospital Food - Medscape - Jul 19, 2005.
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