Echeverri S, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):63-75.





The Cartagena Declaration from
interdisciplinarity

La Declaración de Cartagena desde la interdisciplinariedad

A Declaração de Cartagena desde a interdisciplinariedade


Sonia Echeverri1*


Received: November 1, 2019. Accepted: November 13, 2019.

https://doi.org/10.35454/rncm.v2supl1.031



1 Hospital Ethics and Humanism Committee, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia. Vice-president FELANPE Central Region

*Corresponding author: Sonia Echeverri

info.fundacionconocimiento@gmail.com



Summary


The Latin American Federation of Nutrition Therapy, Clinical Nutrition and Metabolism (FELANPE), in its general assembly held last May in the city of Cartagena, raised the right to nutritional care and the fight against malnutrition to the category of human right. The Cartagena Declaration, which through 13 Principles addresses the worrying problem of malnutrition, in all its forms, indicates how to raise awareness about this scourge that is much talked about, investigated, assumed, palliated, we obtain some results, but we can rarely beat it.

Thus, it is recognized that malnutrition is a complex problem, requiring complex treatments, which are optimized when disciplines related to nutritional activity such as medicine, nursing, nutrition, pharmacy and rehabilitation, among others, decide to join efforts based on their knowledge and respecting the disciplinary competences, as was explicit in Principle # 4 of the Cartagena Declaration focused on the interdisciplinarity of nutritional care, and as reflected by Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, authors who integrate this article which is about this Principle.

In conclusion, by signing the Cartagena Declaration, the societies, associations and schools that make up FELANPE, pledged to recognize the importance of promoting equitable disciplinary integration to provide optimal nutritional care, both in healthcare and academia, as scientific evidence proves.

Keywords: Cartagena Declaration; Mal-nutrition; Interdisciplinary; Principles.


Resumen


La Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo (FELANPE), en su asamblea general realizada en el pasado mes de mayo en la ciudad de Cartagena, elevó a la categoría de derecho humano el derecho al cuidado nutricional y a la lucha contra la malnutrición. En la Declaración de Cartagena, la cual a través de 13 Principios aborda el preocupante problema de la desnutrición, en todas sus formas, indica la manera de crear conciencia sobre este flagelo del que mucho se habla, se investiga, se asume, se palia, se obtienen escasos resultados, pero al que pocas veces se consigue vencer.

Se reconoce, entonces, que la malnutrición es un problema complejo, que requiere tratamientos complejos, los cuales logran ser optimizados cuando disciplinas relacionadas con la actividad nutricional como medicina, enfermería, nutrición, farmacia y rehabilitación, entre otras, deciden sumar esfuerzos basados en sus conocimientos y respetando las competencias disciplinares, como quedó explícito en el Principio # 4 de la Declaración de Cartagena enfocado en la interdisciplinariedad del cuidado nutricional, y como lo reflejan Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, autores que integran este artículo que trata sobre dicho Principio.

En conclusión, al firmar la Declaración de Cartagena, las sociedades, asociaciones y colegios que conforman la FELANPE, se comprometieron a reconocer la importancia de promover la integración disciplinar equitativa para brindar un óptimo cuidado nutricional, tanto en la asistencia como en la academia, según lo demuestra la evidencia científica.

Palabras clave: Declaración de Cartagena, desnutrición, interdisciplinariedad, principios.


Resumo


A Federação Latino-Americana de Terapia Nutricional, Nutrição Clínica e Metabolismo (FELANPE), em sua assembleia geral realizada em maio passado na cidade de Cartagena, elevou o direito ao cuidado nutricional e o combate à desnutrição à categoria de direito humano, Declaração de Cartagena, que através de 13 princípios aborda o preocupante problema da desnutrição, em todas suas formas, indica como aumentar a conscientização sobre esse flagelo que é muito comentado, investigado, assumido, aliviado, com poucos resultados, mas raramente é abatido.

Reconhece-se, então, que a desnutrição é um problema complexo, que requer tratamentos complexos, otimizados quando disciplinas relacionadas à atividade nutricional, como medicina, enfermagem, nutrição, farmácia e reabilitação, entre outras, decidem unir esforços com base em seus conhecimentos. e respeitando as competências disciplinares, como foi explicitado no Princípio nº 4 da Declaração de Cartagena, focado na interdisciplinaridade do cuidado nutricional, e refletido por Humberto Arenas, Alexandra Texeira, Gil Hardy, María Isabel Pedreira, autores que integram este artigo que trata deste Princípio.

Concluindo, ao assinar a Declaração de Cartagena, as sociedades, associações e escolas que compõem a FELANPE comprometeram-se a reconhecer a importância de promover uma integração disciplinar equitativa para oferecer um atendimento nutricional ideal, tanto no atendimento quanto na academia, de acordo com evidências científicas.

Palavras-chave: Declaração de Cartagena, desnutrição, interdisciplinaridade, princípios.


Introduction


Principle # 4 of the Cartagena Declaration correctly guides nutritional care towards interdisciplinarity: “This approach involves the equitable integration of the various disciplines related to nutritional activity. Scientific evidence shows the advantages of this approach in terms of cost-effectiveness, safety, efficiency and efficacy.”(1)

Malnutrition, in all its forms, is an alteration with a high degree of complexity and uncertainty, and should be addressed as such. This complexity makes it necessary for diverse disciplines to participate, focusing their attention and actions to interact with one another sharing knowledge, experience and objectives.

For over four decades, when Dr. Stanley J. Dudrick used parenteral nutrition with the known outcomes, he did so with the help of a health team conformed by nursing, pharmaceutical and nutrition professionals, an initially multidisciplinary one which then began to migrate to interdisciplinarity. Since then, it has been recognized that the contribution of each discipline is, to a great extent, responsible for the success of nutritional therapy: saving lives, enabling patients condemned to die due to the impossibility of using the digestive tract to be nourished, to recover, progress.


Interdisciplinary Nutritional Care


Interdisciplinary, a term coined by sociologist Louis Wirtz and first published in 1937. Interdisciplinarity, whose prefix inter anticipates that a relationship will be established between the disciplines, one in which every one of them will contribute, within their field and competence, the different conceptual analysis schemes, subjecting them to comparison, critical judgement and, finally, incorporating and integrating results with the purpose of solving a concrete problem in all its complexity, in this case malnutrition, object of study and care(2).

As proposed by Mario Tamayo y Tamayo, interdisciplinarity is an internal demand of sciences. Let us take the case of medicine, nursing, nutrition, pharmacy, rehabilitation, psychology, each of them considered particularly, can be considered a level of science, whose purpose is to maintain health, prevent, treat, cure or palliate diseases, among others, applies structured processes, which respond to a dynamic of their own and which develops as each system, of its own discipline, connects to, relates to and coexists with the other disciplines(2).

Therefore, confronting the scourge of malnutrition (undernourishment or obesity), a broad and complex phenomenon, requires the concurrence of various health disciplines, each of which has specific competences within their curricular context and with a common structure or base whose reality is defined, studied, researched and developed from an own perspective. With this foundation (for the issue that concerns us, in research and assistance), disciplines start intertwining, being integrated, giving each other a cohesion of knowledge, forming groups or teams that enrich each discipline at a personal level, professionally, optimizing the nutritional care provided to the patient, family, caregivers and the community.

However, disciplines adopt diverse ways of coexisting, of working as a team, of producing knowledge, such as multidisciplinarity, pluridisciplinarity, interdisciplinarity, intradisciplinarity and transdisciplinarity, each type having its own characteristics, specific dynamics and different nuances. In general, Nutritional Support Teams (NST) embrace multidisciplinarity: “a set of disciplines with common objectives that do not maintain collaborative relationships with each other.”

Some scholars of economic issues related to health policies propose that transdisciplinarity, defined as “the transformation and integration of knowledge from all interested perspectives to define and address complex problems” or “Process according to which the limits of individual disciplines are transcended to address problems from multiple perspectives with the aim of generating emerging knowledge”, might increase the benefits, in financial terms(1).

The Cartagena Declaration approaches the subject of nutritional care from the Interdisciplinarity perspective due to all the advantages it brings along with it among which is its essence: it is the sum of knowledges, scientific methods, abilities and disciplinary skills that allow solving complex problems that surpass the limits and competences of each discipline, creating new knowledge, finding certainty in situations of uncertainty, complementing deficiencies with the objective of optimizing nutritional care and fighting against malnutrition, contributing to society’s well-being and therefore economic progress(1,3).

Consequently, recognizing the importance of the interdisciplinary approach in nutritional care has implications that are mainly academic, but also for health organizations and institutions. The administration of nutritional therapy must be done within the framework of nutritional therapy teams where, as a minimum, nutrition, nursing, medicine and pharmacy professionals participate. Additionally, the inclusion of other disciplines such as phono audiology, occupational therapy, physical therapy, rehabilitation, social work and psychology, which increase the effectiveness of nutritional therapy, complement each other, but most importantly that it should be done with ethics, humanism, recognizing the other as equal, respecting differences, diversity, nutritional care should be provided valuing and appreciating the sick person’s vulnerability and human dignity (Figure 1).

In 1999, Dr. Óscar Jaramillo, in a communication to FELANPE, in support of the creation of the Interdisciplinary Course on Critical Nutrition, CINC, wrote: “The problems that must be solved day after day, do not present themselves to us – for our fortune or our disgrace- classified in disciplinary blocks. Nature, in its admirable wisdom, does not allow – with very few exceptions – only one of its individuals to be responsible for changing its course”. “... The intention is for an interdisciplinary work to originate –by spontaneous generation- from a non-interdisciplinary education given to students, forgetting that university formation rarely offers students the opportunity to interact with other disciplines”. In this sense, the Cartagena Declaration recommends that: From the academic point of view, not only should the professionals in these disciplines be formed in the field of clinical nutrition, but specific disciplinary competences should also be defined and respected.



Figure 1. Teamwork models for nutritional care.







Importance of the Cartagena Declaration on the right to nutritional care and the fight against malnutrition. From the medical perspective

Importancia de la Declaración de Cartagena sobre el derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la perspectiva médica

Importância da Declaração de Cartagena sob o direito ao cuidado nutricional e a luta contra a desnutrição. Do ponto de vista médico


Acad. Dr. Humberto Arenas Márquez, FACS-FASPEN*.



1 Director of the Integrated Intestinal Failure Unit, Hospital San Javier , Guadalajara, Jalisco, México. President of FELANPE 2017 – 2018.

*Corresponding author: Humberto Arenas Márquez

arenas50@hotmail.com


Evidence shows that the rate of prevalence of hospital malnutrition is alarming and that its associated care costs increase exponentially(4,5); undoubtedly, optimal nutrition is intimately related to the positive outcome in disease management(6) ; therefore, it would be ideal for a nutritional plan to be applied to every sick person who enters a hospital(7,8). However, reality is different; the doctor leading the care team has not been trained to face this challenge and, what is worse, is not conscious of this need.

Based on the Hippocratic ethical principle “First, do no harm”, the FELANPE has presented the Cartagena Declaration in 2019 and defined 13 principles to raise awareness, especially among doctors and Health System leaders in Latin America, about the right held by patients to an optimal in-hospital nutrition through the creation of an Institutional Culture that values nutritional care(9).

The doctor, as the leader of the interdisciplinary health team, through his or her attitude and making use of his or her competences such as intelligence, effort and charisma must be able to improve his or her self-awareness and that of his or her collaborators to create a coalition capable of transforming its hospital environment, and thus integrate the process of nutritional care into the Institutional Safety Culture(10) whose objectives are: the identification and control of risks that can cause nutritional harm to patients, the prevention of harm and providing a safe environment to supply optimal nutrition at all times and under any circumstances.

On the other hand, the culture of safety is a matter of ethics and is linked to efficiency, given that a safe doctor is not the one that is most competent in a skill, but rather the one that is most honest in recognizing their own competence and ability limitations and that has enough courage to ask for help and is committed to learn beyond their limitations, especially in the nutritional area(11).

Such cultural shift is a precondition for action that will lead to a policy to improve the patient’s nutritional care process with a policy of measuring outcomes and with them the capacity to act in the political field(12).

Undoubtedly, trust is the cornerstone of the doctor-patient relationship(13). The concept of vulnerability is particularly relevant when the state of dependency is related to the disease; therefore, the sick person trusts us medical professionals to provide them a responsible and dignified care by recognizing their integrity to maintain their health and coordinate a care focused on the patient’s needs so that patients perceive that they are protected when they are most vulnerable.

Although we have significant advances in the medical sciences, practices have not evolved. In order to achieve the objectives of the Cartagena Declaration, we need a unified goal that allows all actions to be aligned.

An objective that has been discussed in debates on healthcare and that can be defined and measured is the addition of value to systems. Porter has developed the theory of value in which the center of attention, and therefore of value, are patients. Value in health is defined as the achieved result for every unit of money invested and is created by a full cycle of care of the person’s medical conditions. Value can be measured using scientific tools (14,15).

Shared responsibility will be achieved through the development of integrated practice units. These integrated systems of care would replace our autonomous and individualistic culture, in which specific departments and specialties work independently and focus on providing a limited range of interventions.


Conclusions


In order to achieve the goals of the Cartagena Declaration, it is essential for a cultural shift to be produced among doctors. Systems must invest in a comprehensive healthcare model that includes optimal nutrition. Investigation of the doctors’ attitude through measurements of their results and costs, as well as patient satisfaction, will allow the identification of interdisciplinary care teams that five value to the patient by including the nutritional process in the institutional culture. This cultural shift will lead to achieving quality care, operational efficiency and financial health for the institution and care providers for the patient’s benefit (16).







The Cartagena Declaration: The role of the Pharmacist

La Declaración de Cartagena: el papel del farmacéutico

A Declaração de Cartagena: o papel do farmacêutico


Prof. Gil Hardy, PhD, FRSC, FASPEN*



1 Profesor Emérito de Nutrición Clínica. College of Health, Massey University, Auckland, Nueva Zelanda.

*Corresponding author: Gil Hardy

gil.hardy50@gmail.com



The Cartagena Declaration: The Role of the Pharmacist


The Cartagena Declaration(9) on the right to nutritional care, outlines 13 important Principles, including the fact that nutritional care should be a continuous process encompassing; Screening, Nourishment and Monitoring. Nourishment by oral, enteral nutrition (EN) or parenteral nutrition (PN) is considered a medical intervention, which like any therapy with side effects, risks and benefits should be monitored and documented. Moreover, the sterile nutrition products used for PN are categorised as pharmaceutical drugs. Principle 4 of The Declaration recognises “The interdisciplinary approach to nutritional care”. It specifically recommends that nutritional care [in hospitals] should be performed by interdisciplinary teams, i.e. a nutrition support team (NST) which should include at a minimum, nutrition professionals (dietitians), nurses, physicians and pharmacists.


A Technical Role

The nutritional care process involves several stages. Pharmacists are well placed and professionally qualified to play a major part in each step, using the knowledge and technical skills developed during their professional training and post graduate experience. In many locations, the formulation and compounding of PN regimens remains the cornerstone of this technical pharmaceutical role. Since the early pioneering days of PN, pharmacists have had responsibility for the preparation of PN. As experts in pharmacology, microbiology, asepsis and pharmaceutical compatibility/stability, pharmacists have contributed significantly to the successful use of nutritional therapy, by formulating stable PN regimens to safely meet individual patient requirements. It is well recognised that safe administration is key to efficacious PN therapy. Many PN components and admixtures are excellent growth media for bacteria and moulds, but any such risks can be minimised when the processes are supervised be pharmacists. Optimum quality can be assured when PN admixtures are prepared by competent technical staff in appropriate aseptic facilities that are routinely monitored.

A substantial body of research data, frequently generated by hospital, academic and industry pharmacists, are available to facilitate judgements on stable and safe formulations. In the absence of pharmaceutical input, poor understanding of all the issues that influence stability can lead to serious, even fatal consequences (17).
On-going training programs for pharmacists and pharmacy technicians must involve understanding the principles and limitations of aseptic techniques, overcoming the belief that any operation carried out under laminar flow automatically results in a sterile product or that a good validation overrides an incorrectly designed or poorly audited facility. There may be a statistical risk of producing ‘infected’ PN bags in a poorly designed, uncontrolled Aseptic Unit operated by inadequately trained personnel. On the other hand, safety and quality can be assured if suitably trained pharmacists, who fully understand the technical processes involved, can nullify the potential microbiological risks by following standard operating procedures and by taking professional responsibility for their actions.


A Clinical Role


Pharmacy participation in daily NST rounds provides a useful forum to help identify unexpected events, such as pyrexia, avoid the unnecessary removal of central lines and improve the likelihood of rapidly identifying the causes of such events that can threaten patient outcomes. His/her specialist knowledge concerning limits for chemical compatibility within which the PN prescription can be formulated is invaluable (18).

The pharmacist can also review the concurrent administration of other drugs and advise ward staff on pharmaceutical aspects of safe administration techniques. The pharmacist’s understanding of drug pharmacokinetics, drug-nutrient interactions (DNI), stability and compatibility will ensure that the most convenient and safe PN admixture can be prescribed for the patient(19). Knowledge of the products available in the hospital formulary and their relative costs can also ensure cost effectiveness of PN therapy. Interdisciplinary collaboration during patient selection and monitoring, catheter placement and catheter care, PN prescription and preparation is essential. In all these operations there are elements of risk and elements of benefit for patients. If the correct balance is found, then the so called ‘hazards of PN’ can be minimised or even eliminated. Involving pharmacists in the patient assessment and prescribing processes, allows these important clinical issues to be addressed.


Multi- Chamber Bags (MCB)


One of the most significant PN developments in recent decades has been the move from multiple bottle systems to single ‘Big Bags’ containing all the daily nutrients. Many PN regimens are still compounded into Big Bags in hospital Aseptic Units, but latterly industry has been able to provide a wide variety of regimens in 2- and 3- chamber bags (MCB). The benefits of delivering PN in a single MCB have been well documented and accepted as the optimum means of safe administration. An unfortunate consequence of the ready availability of MCB with long shelf lives coupled with the increasing regulatory pressures on GMP etc has been the abandonment of PN compounding by many hospital pharmacies and closure of their Aseptic Units. Nevertheless, MCB as supplied by the manufacturer, are not ‘All-in-One’ regimens and still require daily aseptic addition of micronutrients. Pharmacists must therefore be vigilant and ensure that all PN additives are made aseptically, under pharmaceutically controlled conditions.


Pharmaconutrition


With continuing clinical interest in ‘nutraceuticals’ for immuno-/pharmaco-nutrition it is likely that there will be expanding focus on the parenteral administration of specific amino acids, such as glutamine, arginine, novel lipid sources, such as fish and olive oils, individual trace elements and antioxidant vitamins, at concentrations greater than RDA. The American Nutraceutical Association has defined ‘nutraceuticals’ as “naturally occurring dietary substances in pharmaceutical dosage forms”(20). This definition certainly encompasses PN components and pharmaconutrients, but it has been estimated that 75% of home users of nutraceutical supplements do not inform their doctor or NST and may not regard them as ‘medicines’. In fact, many nutraceuticals are potent medications with some health benefits but may have potentially adverse effects when interacting with PN or EN. We are already aware of interactions between thiamine/bisulfite, cysteine/copper, selenite/ascorbic acid, lipids/peroxides. We know that glutamine effects methotrexate pharmacokinetics in cancer patients and methionine increases the incidence of oxoprolinuria in females on low protein diets. Increasing clinical demands for supplementing EN and PN regimens with pharmacological doses of these nutraceuticals for treatment of specific diseases will require even more pharmaceutical involvement for aseptic compounding of patient specific pharmaconutrition regimens. Not Less!


A Teaching Role

Pharmacist’s expertise and training in pharmacokinetics, DNI and microbiology makes them a principle source of knowledge, advice and education for health professionals and PN patients. As a key member within the interdisciplinary NST, the pharmacist can ensure colleagues develop better awareness of potential medication risks at the patient assessment stages. Expertise in medication counselling, allows the pharmacist to educate and advise patients on preparation, storage and administration of PN at home (HPN). Education and on-going training of fellow NST members and HPN patients in aseptic techniques for handling PN and co-administration of other medications is a key pharmaceutical responsibility. Centralisation of all prescription-derived records and patient monitoring records in the pharmacy, can form an essential part of the PN patient’s care plan and will facilitate regular audits for constantly improving team performance in the fight against disease related malnutrition, as advocated by The Cartagena Declaration.







The right to nutritional care and the fight against malnutrition. From the Nutritionist’s point of view

El derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la óptica del Nutricionista

O direito ao cuidado nutricional e a luta contra a desnutrição. Do ponto de vista do Nutricionista


María Alejandra Texeira ND., MSc.1*, Yadira Cortes ND., Ph.D.2, Edna Nava3, Laura Joy, ND., Ph.D.4



1 Head of the Human Milk Bank, Hospital Regional Salto, Salto, Uruguay. Head of the Nutritionist Committee of FELANPE 2019 - 2020.

2 Nutrition and biochemistry department, Pontificia Universidad Javeriana, Bogotá, D.C., Nutritionist Committee of FELANPE, central region, 2019 - 2020.

3 Universidad Autonoma de Nuevo León, México. Nutritionist Committee of FELANPE, north region, 2019 – 2020

4 Instituto Nacional de Cáncer, Paraguay. Nutritionist Committee of FELANPE, southern region, 2019 – 2020

*Corresponding author: María Alejandra Texeira

alejandratexeira@gmail.com


The reflection focused on the Cartagena Declaration(9) by the Committee of Nutritionists of the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) leads us to ask ourselves: What is our responsibility as professionals and as a group with regard to these rights?

The answer, undoubtedly, is that as professionals and as group we have the responsibility of contributing to the promotion of the right to nutritional care and the fight against malnutrition, and to the advancement in terms of education and research in clinical nutrition, so that they become a reality and not just theoretical statements that are not put into practice.

While the statements of principles and norms are important, without feelings, attitudes and inner conviction, we will not achieve the expected outcomes. As nutrition professionals, we believe that knowing the Declaration is not enough, but that it is necessary to embrace its spirit and implement it.

As a collective, it is our duty to defend this right not only by complying with it from the exercise of our daily practice, but, additionally, we must ensure that it is respected and fulfilled, avoiding falling into a situation of complicity or failure by omission.

JL Aranguren raises the following question: can the man who accepts, at least with his passivity and his silence, an unjust social situation be considered a truly good man?(21)

Transferring Aranguren’s question to the context of the Cartagena Declaration, we ask ourselves: can the Nutritionist who accepts, at least with his passivity, the violation of the right to nutritional care and everything this implies, be considered good?

It is the Nutritionist’s responsibility to participate in the formulation and implementation of policies for the positive fulfillment of the principles of the Cartagena Declaration, to analyze governmental structures and policies and, simultaneously, to carry out research in nutrition and health that contributes data for the elaboration of these policies.

Demonstrating, through clinical research, that the interventions of the nutrition professional solve problems and help people have full enjoyment of their rights to adequate nutritional and health status, is an individual commitment as professionals and additionally a matter of guild and social responsibility.

We nutritionists must perform a practice that prioritizes the preservation of people’s rights and promotes the acknowledgement of nutrition and health as a human right, advocating for the people who are under our care.

We believe that, driven by the Cartagena Declaration, we must form academic and ethics study groups, with professors, researchers and clinicians, with the purpose of achieving a higher convergence between theory and practice, committing ourselves not only to be a good Nutritionist, but also a prepared, updated, ethical, guild-conscious and professional Nutritionist.







International declaration on the right to nutritional care and the fight against malnutrition. From the Nursing perspective

Declaración Internacional sobre el derecho al cuidado nutricional y la lucha contra la malnutrición. Desde la perspectiva de Enfermería

Declaração internacional sobre o direito aos cuidados nutricionais e o combate contra à desnutrição. Na perspetiva da Enfermagem


María Isabel Pedreira de Freitas1*



1 Past president of the Nurse Committee of FELANPE

*Corresponding author: María Isabel Pedreira de Freitas

>beloca4@yahoo.com.br


In May 2019, the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE), in a general assembly, approved the International Declaration on the Right to Nutritional Care and the Fight Against Malnutrition, named the Cartagena Declaration.

The nursing personnel daily witness patients who develop malnutrition during their hospitalization or who arrive at health institutions in a deplorable state of malnutrition(22). This situation largely afflicts people who remain 24 hours a day next to those who seek an answer to their health needs. There are publications of evidence-based studies(23), in which patients who remain fasting for surgery, for a longer time than is recommended, put their recovery at risk(24). However, in many health institutions, there is still resistance to making modifications to this practice that may compromise the surgical patient’s life.

As nurses, what do we have to do with this Declaration, knowing that together with patients and their families, we act in the same field as doctors?


We have a lot to do!


It is a fortune to know that States around the world, presided over by Dr. Tedros Ghebreyesus, Director-General of the World Health Organization, WHO, and the International Council of Nurses, ICN, during the opening of the 72nd World Health Assembly, established 2020 as the Year of the Nurse and midwife, giving birth to Nursing Now.

This campaign states that “While it is true that the WHO recognizes the crucial role that nurses play on a daily basis, 2020 will be dedicated to highlight the enormous sacrifices and contributions of nurses and midwives, and… seeks to train nurses to take their place at the heart of the health challenges of the 21st century and maximize their contribution to achieve Universal Health Coverage.”(25)

Walking next to health professionals that support the Cartagena Declaration, means that Nursing can optimize every step towards meeting the challenges that healthcare demands, taking into account that “to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity”(9) is one of the objectives of the Declaration.

Who better than the nursing team that accompanies the patient in their hospitalization at different moments in which their clinical conditions change, causing changes in the therapeutic behaviors that will affect their recovery and overall status?

Nurses are able to observe and act on “factors as diverse as education, economic status, social capital and the physical environment profoundly affect the health and well-being of individuals and populations” as stated by one of the principles of the document Nursing Now(25).

By conceiving nutritional care as “a continuous process consisting of several stages which can be summarized as follows: 1. Screening, 2. Nourish and 3. Watch”, as proposed by the Cartagena Declaration, the caregiver who is closest to the patient and can act immediately upon detecting the alterations present in the patient’s evolution and consequently provide care, is the Nurse. The Nurse acts throughout the entire assistance process with a strong post-operative care teaching approach, directly associated with a better patient recovery, in the same way that continuous assessment and monitoring are very well defined in the nurse’s role(26).

As stated by the Cartagena Declaration, “Nutrition therapy should be monitored and documented. Monitoring seeks to verify that the different dimensions of nutrition therapy are met and to prevent side effects. Documentation serves to track and evaluate the continuity of therapy for each patient and to ensure quality.”(9) It will be the nurse’s leadership in assistance what will favor the fulfillment of this record and the monitoring of the complications that occur during the patient’s hospitalization process. It is these actions, based on the results obtained in successful experiences lived in the day-to-day life with patients, citizens, caregivers, what made the proposals recorded in the document Nursing Now and the Cartagena Declaration possible, which pleasingly walk towards the same objective, shoulder to shoulder, optimizing the outcomes that must be achieved.

Being aware that “clinical nutrition research is a pillar for the realization of the right to food in the clinical field and the fight against malnutrition” makes it necessary to promote “the teaching of clinical nutrition in health careers (medicine, nutrition, nursing, pharmacy, etc.).”(9) Therefore, interdisciplinary action in the formation of students in health areas is fundamental, since the beginning of curricular formation, to achieve an effective and coherent interaction in order to obtain the best results in clinical practice.

In order for the patient to be fed and adequately nourished, it is necessary for each person to carry out concrete actions. Caregivers must act knowing the cultural level of each patient and their family, with the purpose of empowering them so that they can continue the health recovery process at home. They will be able to make the best decisions based on the freedom that knowledge provides, identifying what is best for them and their health. That freedom can be attained by incorporating the training and teaching that the nurse developed with their team and transmitted to the patient during their hospitalization process, thus optimizing the obtained results during the teaching-learning process(27).

The Cartagena Declaration strengthens the actions that health teams must develop together with people who seek to improve their health when it is compromised.


Financing


This article was not financed.


Conflict of interests


The author declares that he has no conflict of interest.


Author’s contributions


SE designed the article. All the authors wrote the manuscript and read and approved the final version.


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