What if the Patient Cannot Speak and Doesnt Want Tube Feeding
The Risks and Benefits of Feeding Tubes for the Elderly
Feeding tubes are used to provide liquid nutrition to individuals who have difficulty chewing and/or swallowing or who are completely unable to eat on their own. The decision to use a feeding tube is often a complex one, especially for older patients. Family caregivers may find themselves responsible for making this difficult choice on an aging loved one's behalf someday, so it is important to understand why and when tube feeding is appropriate. Unfortunately, the information that medical professionals provide on this topic is not always very clear or accurate.
Types of Feeding Tubes
There are several kinds of feeding tubes that are used for different reasons and for different lengths of time. The name of each type of feeding tube typically describes its insertion point and/or ending point in the body.
Non-Surgically Inserted Feeding Tubes
Temporary feeding tubes are introduced via the nose (nasal) or mouth (oral). Depending on where nutrition, fluids and/or medication must be delivered in the body, the tube may end in the stomach (gastric) or one of two areas of the small intestine called the duodenum (duodenal) or the jejunum (jejunal). For example, a nasogastric tube (NG tube) is inserted via the nose and ends in the stomach, while an orogastric tube (OG tube) is inserted via the mouth and ends in the stomach.
Non-surgically inserted feeding tubes are typically used for short-term tube feedings while a person heals and their ability to eat safely improves. Their use for longer than a couple of weeks can cause severe irritation and injury to the tissues of the nose, throat and esophagus.
Surgically Inserted Feeding Tubes
Percutaneous feeding tubes are surgically inserted via an incision in the abdominal wall called a stoma or ostomy. These more invasive tubes are typically placed for long-term or permanent use, but they can be removed if a patient regains the ability to eat and drink on their own. Like nasal and oral tubes, percutaneous tubes may end in the stomach (known as a gastrostomy tube or G-tube) or in the small intestine (known as a jejunostomy tube or J-tube).
Why Are Feeding Tubes Used?
There are many reasons why people of all ages may require a feeding tube either temporarily or permanently. Certain head, neck and esophageal cancers can prevent patients from eating normally, as can head trauma, traumatic brain injury (TBI), stroke, and neurological disorders like dementia and Parkinson's disease. Feeding tubes may also be recommended for individuals who refuse to eat and have become malnourished.
Family members of seniors who have advanced Alzheimer's disease or related dementias are often urged to consider feeding tube placement. This is usually because late-stage dementia patients develop a condition called dysphagia, where they lose the ability to chew and swallow safely. In addition to ensuing undernutrition, dysphagia increases a patient's risk of inhaling food or drink and developing aspiration pneumonia, a serious lung infection that can be fatal.
In other cases, a feeding tube may be required if a person has been placed on a ventilator to help them breathe. Use of a ventilator often requires a surgical procedure called a tracheostomy to create a surgical airway in the trachea. A tube called a trach tube is placed in this opening to clear secretions in the lungs, but the trach tube also prevents a patient from taking food and drink by mouth.
The Controversy Over Artificial Nutrition and Hydration at the End of Life
For many seniors who are not conscious or mentally capable of making their own health care decisions, the choice to use a feeding tube typically falls to their agent under a medical power of attorney or legal guardian. The idea of a loved one no longer eating or drinking is disturbing for most people to consider, especially because it is their responsibility to make the best possible care decisions and minimize discomfort. However, the placement of a feeding tube is not a simple fix that is free of complications or risks.
A type of abdominal tube called a percutaneous endoscopic gastrostomy or PEG tube (named for the procedure used to place it) is usually what medical professionals recommend, especially for patients with late-stage dementia who can no longer eat or refuse to do so. Placement of the tube is not particularly difficult or risky, but complications may arise from the incision and its ongoing use.
PEG tubes are meant to prevent aspiration, minimize the risk of pneumonia, increase nutritional intake and help fortify the immune system to promote healing and functionality, but research has failed to show that such aggressive intervention delivers these benefits. Infection and leaking of the surgical site are concerns, and aspiration is still a possibility. Furthermore, a patient may need to be physically or chemically restrained to prevent them from forcibly pulling out their feeding tube.
Disinterest in or refusal of food and drink are common symptoms at the end of life, regardless of what health conditions are present. This is a natural step in the progression towards death as the body begins to shut down normal processes like digestion. In fact, consumption of food and fluids may even cause discomfort for some terminal patients.
The best alternative to tube feeding for seniors with severe dementia is careful hand feeding. In a position statement, the Alzheimer's Association emphasizes that "careful hand feeing offers the highest quality of care and should be offered to all individuals with advanced Alzheimer's disease who can competently and comfortably handle oral feeding."
During this process, trained aides will offer food that is typically pureed and/or thickened and read a patient's verbal and nonverbal cues to determine whether they are hungry, thirsty or experiencing any discomfort. Hand fed patients are carefully observed to prevent aspiration and are not forced to eat or drink if they do not show any interest in the process. Family members can also participate in hand feeding, which adds a valuable social component to meal times.
Unlike tube feeding, hand feeding is a time-consuming process that requires total one-on-one supervision. Doctors at skilled nursing facilities and hospitals may overstate the benefits of feeding tube placement because this option is easier and faster for staff members to handle.
The Decision to Place a Feeding Tube
Feeding tubes of all kinds certainly serve an important purpose, primarily for individuals who are not in the late stages of an untreatable illness. Unfortunately, tube feeding is not beneficial for all patients who cannot eat or who refuse to eat, but this intervention should be considered on a case by case basis. In a position statement, the American Academy of Hospice and Palliative Medicine recommends that "[artificial nutrition and hydration] should be evaluated by weighing its benefits and burdens in light of the patient's clinical circumstances and goals of care."
This is just one important end-of-life issue that many seniors and family caregivers face. It is crucial for families to discuss preferences for end-of-life care and put them in writing early on to avoid confusion and ensure one another's wishes are respected. Living wills and advance directives, such as do-not-resuscitate (DNR) orders and physician orders for life sustaining treatment (POLST) forms, are vital for recording end-of-life care choices and should include if, when and for how long an individual wants to be fed in this manner.
Ultimately, choosing whether to elect tube feeding for oneself or as an advocate for someone else is not an easy task. Thoroughly discussing the pros and cons of feeding tubes—as well as alternatives—takes time and effort for medical professionals and families, but it is well worth the investment. Working closely with a loved one's health care team is the best way to gain a complete understanding of the difficult ethical principles and medical options at hand.
Sources: Nasogastric feeding tube (https://medlineplus.gov/ency/patientinstructions/000182.htm); Feeding tube insertion – gastrostomy (https://medlineplus.gov/ency/article/002937.htm); Jejunostomy feeding tube (https://medlineplus.gov/ency/patientinstructions/000181.htm); Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits (https://dx.doi.org/10.1155%2F2019%2F7272067)
Source: https://www.agingcare.com/articles/the-risks-and-benefits-of-feeding-tubes-for-seniors-445699.htm
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