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Temporal hollowing (loss of temporalis muscle bulk) and prominence of clavicles or scapulae are indicators of muscle wasting. Orbital fat pad loss and triceps skinfold reduction reflect fat loss, not muscle. Edema is nonspecific, often masking malnutrition. Proper nutrition-focused physical exam (NFPE) identifies muscle and fat stores separately, informing malnutrition diagnosis. Muscle loss predicts poor outcomes, including weakness, infection risk, and prolonged recovery. Regular NFPE ensures early recognition and intervention.

Ethical nutrition support practice prioritizes patient autonomy. Competent adults have the right to refuse or discontinue medical interventions, including artificial nutrition. Continuing PN against the patient’s wishes constitutes battery and violates autonomy. Withdrawing PN is ethically and legally distinct from euthanasia; it allows natural progression of disease while focusing on comfort. The nutrition team’s role is to confirm decisional capacity, ensure the patient understands risks/benefits, and involve palliative care. Families may struggle emotionally, but substituted family preferences cannot override a competent patient’s decision. Compassionate support, communication, and symptom management remain central responsibilities.

The hallmark of refeeding syndrome is hypophosphatemia, caused by insulin-driven intracellular shifts during carbohydrate refeeding. It leads to respiratory failure, arrhythmias, and rhabdomyolysis. Hypokalemia and hypomagnesemia also occur but phosphate deficiency is most critical. Prevention includes slow feeding initiation, thiamine supplementation, and electrolyte monitoring.

Excess lipid infusion overwhelms clearance, causing hypertriglyceridemia (>400 mg/dL), pancreatitis risk, and immune dysfunction. Lipids should be infused at ≤1 g/kg/day in critically ill patients. Hypoglycemia, hypophosphatemia, and hypokalemia are unrelated to lipid overload.

Refeeding syndrome is driven by insulin release upon reintroduction of carbohydrate, which shifts phosphate, potassium, and magnesium into cells. Hypophosphatemia is the hallmark abnormality, leading to impaired energy metabolism, respiratory failure, and arrhythmias. Hypokalemia and hypomagnesemia also occur, but phosphate depletion is most critical. Prevention involves slow initiation of feeds, correction of electrolytes, and thiamine supplementation before nutrition.