Tube Feeding

                  Feeding tubes are used for a number of  reasons.  These include the  impairment of swallowing by  neurological problems such as stroke, the use of a ventilator for breathing, after surgery for head and neck tumors, and for people who for a variety of  reasons are simply unable to take adequate nutrition by mouth. In the nursing home this may include   residents with advanced dementia who at some point simply lose the ability to take food and fluid by mouth.

  

The decision to undertake tube feeding is a very personal one.  This is particularly true when a resident is in the terminal stages of an illness such as cancer, heart or lung disease, or Alzheimer’s disease.Such a decision, like a decision concerning cardiopulmonary  resuscitation, depends on the individual’s values and preferences.  There is no definite “right” or “wrong” decision.

  

Tube feedings can enhance and prolong life in some situations. One example would be a patient who is ill but expected to recover.Another example would be a person who is unable to eat normally but is otherwise functioning well. However, there is a growing consensus that they do not help  significantly in the presence of   end-stage disease.A large number of persons with severe dementia who have feeding tubes placed die within a few weeks or months anyway. In addition, feedings by nasogastric (NG) and gastrostomy (“PEG”) tubes do carry potential complications, including infection,leakage,diarrhea,overloading with fluid and metabolic abnormalities. In most patients, feeding tubes do not eliminate the risk of aspiration (choking).

  

Eating, with its associated human contact, is a very important social and psychological ritual in most   societies, including our own.  For a person in the last days to weeks of life, the benefits of attempts at oral feeding, even if intake is not enough to sustain life, may outweigh those of tube feedings.  Persons at this stage of life should have comfort as the main goal of care. 

  

           The best time to make any decision concerning expectations of care is well in advance of the need.   It is very important to us that the health care team knows in advance of a resident’s wishes concerning the use of tube feeding.  If a resident lacks the capacity to make a decision about tube feeding, a   family member or other surrogate will be approached.In New York State, a surrogate may refuse feeding tube placement if there is clear and convincing evidence that the resident would not have wanted the feeding tube.

  

           The members of the team, particularly the physician, nurse practitioner and social worker, are interested in and available for discussion of this and any other advance care planning issues. 

  

Key Points

  

          Feeding tubes can improve the quality of life for some patients, such as those with acute strokes and certain tumors.

  

 People who are functioning well can live with feeding tubes for years.

  

 Feeding tubes probably prolong life very little in the presence of end-stage disease.

  

 Feeding tubes may or may not provide comfort to a severely ill patient; each situation is different and should be discussed among the caregivers.

  

  In most cases, feeding tubes do not prevent aspiration (choking).

  

 It is best to anticipate the need for alternative feeding methods in advance so that the team can discuss the situation, and it is best for the patient to make the decision.

  

 In New York State, a relative may refuse the placement of a feeding tube in a patient who lacks the capacity to decide if there is clear evidence that the patient would not have wanted the tube.