‎The Canadian Oncology Nutrition Standards of Practice presented in this document form the basis of the work of dietitians working in comprehensive cancer care settings in Canada. Oncology Clinical Nutrition Services exist in a variety of settings, including hospitals, comprehensive cancer care facilities, satellite clinics, and multipurpose public health clinics in urban and rural communities throughout Canada. 

The working group recognised that there are discrepancies in the access, provision and delivery of clinical nutrition services within and between provinces. As well, prior to this endeavour, Canadian Oncology Nutrition Standards of Practice did not exist. 

The Oncology Nutrition Standards are designed to bridge this gap and to guide administrators and professionals in the development and maintenance of Oncology Nutrition Services. The Oncology Nutrition Standards apply to a range of Oncology Nutrition Services for clients, their families and caregivers within comprehensive cancer care facilities and may be adapted to other settings as required. 

This document includes six sections containing 29 Standards of Practice. Sections I and II address Foundations (Organization and Structure; Professional Attributes), and Sections III through VI relate to Programs and Services (Provision of Oncology Nutrition Services; Research; Education and Training; and, Evaluation). 

A copy of these standards can be downloaded from the Dietitians of Canada's web site athttp://www.dietitians.ca/public/content/career_in_nutrition/index.asp Permission is granted to reproduce copies of the document in its entirety for personal or educational purposes, provided credit to the publishers is included. 

© 2004 Dietitians of Canada. All rights reserved

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The involvement of oncology dietitians in patient care spans the continuum of the cancer experience including primary prevention, cancer treatment, secondary prevention, cancer recurrence, and palliative care.

The key to providing effective oncology nutrition care is anticipating and diagnosing deterioration in nutritional status, and then preventing its onset or rectifying it before it reaches clinical significance.

Optimal oncology nutrition care mandates proactive, standardized screening, assessment, intervention and regular monitoring (Shils, 1979; Ottery, 1994, 1995, 1996; Bauer, Capra and Ferguson, 2002).

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Progressive deterioration in nutritional status is common in persons living with cancer. The incidence of malnutrition during the course of cancer ranges from 30 to 90 percent and varies according to the type, location, grade and stage of tumor, tumor spread, anticancer treatments, and individual susceptibilities (Nitenberg and Raynard, 2000; Capra, Ferguson and Reid, 2001). Weight loss and malnutrition are associated with delayed healing, treatment alterations, increased risk of complications and death, and impaired quality of life (Ottery, 1995); compromised immune function (Gogos, Ginopoulos and Salsa, 1998); longer hospitalizations (Ottery, 1995; Bauer, Capra and Ferguson, 2002); and readmission within 30 days of discharge (Bauer, Capra and Ferguson, 2002).

Also significant is the role of nutrition in cancer survivorship. As more people surviving cancer endeavor to prevent cancer recurrence and second primary tumors, demand for nutritional guidance will increase (Brown et al, 2001). Although scientific evidence is not sufficient to provide firm guidelines for cancer survivors at present, oncology dietitians assist clients in making informed choices based on the current scientific information.

Section III: Oncology Nutrition Services 
  
Oncology Nutrition Services consist of: 
  
A. Nutritional Care for Individuals 
B. Nutrition Education for Groups 
C. Management of Practice 
  
A. NUTRITIONAL CARE FOR INDIVIDUALS 
  
STANDARD 17 - Access to Services  
Referrals for Oncology Nutrition Services are accepted from clients, family members/caregivers, health care providers or community agencies.  
  
STANDARD 18 - Nutrition Screening  
Oncology dietitians collaborate with other health care providers to ensure the organization has a nutrition screening mechanism to identify clients at nutritional risk.  
  
STANDARD 19 - Nutrition Consultation  
Oncology dietitians: 
  
a. provide nutrition intervention in a proactive manner. 
  
b. perform nutrition assessment (considering diagnosis; treatment; other co-morbidities; diet history; physical examination; laboratory data; medications; clinical symptoms; and psychosocial, cultural, and educational factors affecting nutritional status). 
  
c. develop client-centered nutrition care goals based on assessment findings and formulate individualized nutrition care plans. 
  
d. provide appropriate follow up, and modify nutrition goals and care plans based on clients' changing nutritional needs and expectations. 
  
e. consult with interdisciplinary team members regarding nutritional care.  
  
 STANDARD 20 - Nutrition Counselling and/or Education  
 Oncology dietitians: 
  
a. collaborate with clients to determine goals and objectives of nutrition counselling and/or education sessions, and select strategies most appropriate for achieving learning/ behavioural goals. 
  
b. ensure nutrition counselling and/or education is/are integrated into nutrition care plans based on assessment of clinical, educational and psychosocial parameters. 
  
c. ensure that nutrition counselling and/or education is/are provided in suitable physical environments with minimal distractions. 
  
d. conduct counselling and/or education sessions utilizing appropriate interpersonal and communication skills. 
  
e. select appropriate education materials suited to client learning needs (see Relevance of Education Materials in Standard 22 - Nutrition Education for Groups). 
  
f. communicate the plan for nutrition counselling and/or education to the health care team.  
  
STANDARD 21 - Continuity of Care 
Oncology dietitians work in partnership with health care and community resources to provide continuity of nutrition services for clients and their families across the cancer continuum. 
  
  
B. NUTRITION EDUCATION FOR GROUPS 
  
STANDARD 22 – Group Nutrition Education  
Oncology dietitians: 
  
a. identify learning needs of clients and/or their families/caregivers, community groups, governing bodies, students, and dietetic colleagues. 
  
b. advise clients and/or community groups of the availability of nutrition education programs and resources. 
  
c. ensure nutrition education programs and resources are tailored to the diversity of intended learners.

C. MANAGEMENT OF PRACTICE 
  
Management of Practice refers to oncology dietitians' management of daily activities that ensure responsible, competent practice and facilitate achievement of clinical responsibilities. 
  
STANDARD 23 - Administrative Responsibilities  
Oncology dietitians: 
  
a. establish priorities for nutrition care delivery based on the urgency and complexity of nutrition intervention. 
  
b. develop and implement standards of practice, clinical practice guidelines, screening practices, protocols, and clinical pathways in conjunction with health care teams and key stake-holders. 
  
c. communicate changes in oncology nutrition policies and practices to relevant committees in health care facilities. 
  
d. maintain and monitor clinical and non-clinical nutrition services workload measures. 
  
e. develop and maintain needs-based education materials and tools for clients and families (individual and group sessions). 
  
f. maintain nutrition product formularies through collaborative approaches involving clinical and management staff. 
  
g. ensure that nutrition education programs and resources are assessed for effectiveness and relevance (per Section VI, Evaluation of Programs and Services).  
  
STANDARD 24 - Health Care Team Members 
Oncology dietitians: 
  
a. provide oncology nutrition knowledge and expertise to the health care team. 
  
b. incorporate the role of nutrition services into the care pathways of relevant tumour site teams.  
  
c. advocate for the provision of nutrition services within comprehensive cancer care. 
  
d. act as client advocates.

STANDARD 25 - Community Liaison 
Oncology dietitians: 
  
a. identify appropriate community partnerships. 
  
b. ensure the progression of client care into the community is seamless and respectful of client well-being and governmental policies. 
  
c. facilitate communication with community partners regarding pertinent clinical and administrative issues.  
 

Section IV: Research 
  
STANDARD 26 - Supportive Research Environment  
Oncology nutrition programs: 
  
a. value and encourage research, and facilitate collaboration between dietitians, clinicians and researchers. 
  
b. develop linkages with other cancer care facilities, hospitals, universities and research organizations. 
  
c. dedicate time for clinicians to participate in research activities. 
  
d. integrate research findings into clinical practice.  
  
STANDARD 27 - Promotion of and Participation in Research 
Oncology dietitians: 
  
a. critically evaluate and apply research findings to assess, provide, and improve patient care, manage services, and educate clients, health care professionals, and others. 
  
b. identify and develop research-based policies, procedures, and clinical pathways as a basis for nutritional care. 
  
c. perform or collaborate to conduct oncology nutrition research (may identify research issues, participate in designing and implementing research projects, facilitate research activities, or disseminate research findings through publications and/or presentations). 
  
d. present research findings at professional meetings, to health care administrators, and the public. 
  

Section V: Education and Training  
  
STANDARD 28 – Participation in Education and Training  
Oncology dietitians: 
  
a. actively participate in facility-related continuing education and training activities regarding oncology issues and practices. 
  
b. provide needs-based education programs within the dietetic community (dietitians, undergraduate and graduate dietetics/nutrition students, dietetic interns), and health professionals to promote quality oncology nutritional care. 
  
c. supervise or mentor dietitians and other health professionals pursuing theses, dissertations, fellowships or other training. 
  
d. evaluate the effectiveness of educational activities. 
  
  
EVALUATION 
  
Section VI: Evaluation of Programs and Services  

STANDARD 29 – Evaluation of oncology nutrition programs and services 
  
Evaluation of oncology nutrition programs and services is integrated into the oncology nutrition program.  
  
Oncology dietitians: 
  
a. systematically evaluate the quality, effectiveness/outcomes and relevance of Oncology Nutrition Services and revise practice as needed. 
  
b. conduct meta-evaluation, involving the ongoing reassessment of priorities and Standards of Practice to support quality practice and provision of services (Joint Committee on Standards for Educational Evaluation, 1994).

American Dietetic Association. (1998). The American Dietetic Association standards of professional practice for dietetics professionals. Journal of the American Dietetic Association, 98 (1), 83-87. 
  
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American Society for Parenteral and Enteral Nutrition. (2000). Standards of practice for nutrition support dietitians. Nutrition in Clinical Practice, 15, 53-59. 
  
American Society for Parenteral and Enteral Nutrition. (2001). Standards of practice for nutrition support dietitians. Journal of the American Dietetic Association, 101 (7), 827-832. 
  
Bauer J, Capra S, Ferguson M. (2002). Use of the scored patient-generated subjective global assessment as a nutrition assessment tool in patients with cancer. European Journal of Clinical Nutrition, 56 (8), 779-785. 
  
Brown J, Byers T, Thompson K, Eldridge B, Doyle C, Williams AM. (2001). Nutrition during and after cancer treatment: A guide for informed choices by cancer survivors. CA Cancer Journal for Clinicians, 51 (3), 153-187. 
  
Canadian Association for Psychosocial Oncology. (1999). Standards of psychosocial oncology services in Canada: Standards of care. 
  
Capra S, Ferguson M, Ried K. (2001). Cancer: impact of nutrition intervention outcome – nutrition issues for patients. Nutrition, 17, 769-772. 
  
Dietitians of Canada. (1997). Professional standards for dietitians in Canada. 
  
Gogos C, Ginopoulos P, Salsa B. (1998). Dietary omega-3 polyunsaturated fatty acids plus vitamin E restore immunodeficiency and prolong survival for severely ill patients with generalized malignancy. Cancer, 82(2), 395-402. 
  
Joint Committee on Standards for Educational Evaluation. (1994). The program evaluation standards: How to assess evaluations of educational programs (2nd edition). Sanders, JR (Ed.). Thousand Oaks, CA: Sage Publications. 
  
Nitenberg G, Raynard B. (2000). Nutritional support of the cancer patient: issues and dilemmas. Critical Reviews in Oncology Hematology, 34, 137-168. 
  
Ottery F. (1994). Rethinking nutritional support of the cancer patient: the new field of nutritional oncology.Seminars in Oncology, 21(6) 770-778. 
  
Ottery FD. (1995). Supportive nutrition to prevent cachexia and improve quality of life. Seminars in Oncology, 22 (2) (Supp 3), 98-111. 
  
Ottery F. (1996). Definition of standardized nutritional assessment and interventional pathways in oncology.Nutrition, 12 (1) S15-S19. 
  
Shils, ME. (1979). Standards of nutrition therapy. Cancer, 43 (Supp 5), 2093-2102.

Comprehensive cancer care facility 
A cancer care facility that provides leadership in co-ordinating and integrating a comprehensive cancer control program; provides high quality interdisciplinary services to patients and their families across the cancer continuum; and is committed to ongoing research and education endeavors.  

Oncology Dietitian 
A registered dietitian who works in a comprehensive cancer care facility.  

Practice Based Research 
Research activities based on issues arising from practice, with findings informing future practice. 
  
Registered Dietitian 
A dietitian in Canada who is registered with a provincial dietetic regulatory body. 
  
Provincial designations include: 
P.Dt (Professional Dietitian): New Brunswick, Nova Scotia, Quebec 
  
RD (Registered Dietitian): Alberta, British Columbia, All Territories, Manitoba, Newfoundland, Ontario, Prince Edward Island, Saskatchewan 

Professional Oath:

As a professional dietitian/nutritionist I pledge to practice the art and science of dietetics to the best of my abilities: 
  
• to maintain integrity and empathy in my professional practice; 
• to strive for objectivity of judgement in such matters as confidentiality and conflict of interest; 
• to maintain a high standard of personal competence through continuing education and an ongoing critical evaluation of professional experience; 
• to work co-operatively with colleagues, other professionals, and laypersons; 
• to protect members of society against the unethical or incompetent behaviour of colleagues or other fellow health professionals; 
• to ensure that our publics are informed of the nature of any nutritional treatment or advice and its possible effects; 
• to obtain informed consent for our invasive or experimental procedures. 

I further pledge to promote excellence in the dietetic profession: 

• to support others in the pursuit of professional goals; 
• to support the training and education of future members of the profession; 
• to support the advancement and dissemination of nutritional and related knowledge and skills; 
• to involve myself in activities that promote a vital and progressive profession.  

Source: http://www.dietitians.ca/