One of the most agonizing decisions families might face can be whether or not to request or approve of a feeding tube for a loved one who is near death. Are we "playing God" by denying tube feeding to our dying loved one as long as he or she can be kept comfortable, or are we "playing God" by requesting tube feeding, with or without medical agreement?

If the dying person left plain instructions about end-of-life medical care, made during a time of good cognition, the decision can be easier, though still fraught with emotional pain. Few of us want to be put in this situation, but many of us find ourselves facing medical people who need to know what we want done.

There's no easy answer. Spiritual and religious views of the decision maker often enter the picture, even if the ill person left explicit instructions. When religious views mesh with the dying loved one's views, the situation is still difficult, but a bit easier than when views clash.

If mom or dad expressed a wish to be kept alive for as long as possible with feeding tubes and/or other medical means, but the family members feel that the suffering has been long and  hard and that the parent would have changed his or her mind at this point, what do they do? If the parent left a living will stating that no feeding tubes or other measures be used to prolong life during this stage, but the adult children disagree with that stance, do they have a right to override the parent's stated wish?

What about the doctor's input? Many people complain that they've never been asked about tube feeding, but they walk into a hospital room and find feeding tubes already in place. Others say that they feel the doctor is trying to talk them out of tube feeding, when they really need to think about the issue or definitely want to try it.

Apparently, where we live also plays into the decision. Joan Teno, professor of community health at Brown University, has documented a striking variation in feeding tube insertion rates depending on the state where the patient lived.

Supported by funding provided by the National Institute on Aging, Teno led a group of researchers from Brown University, the Hebrew Senior Life Institute for Aging Research in Massachusetts, and the University of Texas Southwestern Medical Center in "asking people to describe the communication they had with physicians surrounding whether to insert a feeding tube for their loved ones."

Teno's team conducted a study of intubation rates of people with advanced Alzheimer's disease based on the states with the very high rates of intubation of people with advanced Alzheimer's disease (Texas, Alabama, and Florida) and with very low rates of intubation of people with advanced Alzheimer's (Massachusetts and Minnesota).  The study was reported on in an article on the Brown University website.

The article reporting on the study is titled Families need information on feeding tubes for elderly dementia patients. The full results can be found in a May 13, 2011 print issue of Journal of the American Geriatrics Society.