Decision to Insert Feeding Tube Needs Careful Consideration
Another one of the hardest things that a family or caregiver has to watch is a loved one with Alzheimer’s struggle with eating and drinking. These difficulties can range from no longer recognizing food to not being able to coordinate the use of eating utensils. But the hardest decision involves what to do when they have difficulty chewing or swallowing or no longer will accept assistance with eating.
As I mentioned in a 2007 sharepost, we faced this decision with my mother. Because of her Alzheimer’s disease and chronic obstructive pulmonary disease, she had difficulty swallowing. A modified barium swallowed test found that she could still consume a modified diet that included mostly pureed food. However, if this progressed, we were going to be faced with the decision of whether to have medical professionals insert a feeding tube. We didn’t get to that point because Mom died five months later.
However, many families still face this type of decision as their loved one’s mental status declines. So what should they do? I found some that the American Geriatric Society has developed some helpful recommendations related to providing sustenance.
The organization encourages physicians, patients and caregivers to question percutaneous feeding tubes in people who have advanced dementia. Instead, this group recommends careful hand-feeding instead because it is not associated with agitation, increased use of physical and chemical restraints and worsening pressure soars. In addition, hand-feeding is deemed as good as feeding tubes as far as issues such as functional status, aspiration pneumonia and death.
AGS points out that research has found a very high mortality in elders who have advanced dementia who are placed on feeding tubes. Some of these studies have found that tubal feeding is associated with aspiration, infection, increased oral secretions that are difficult to manage, tube malfunction, pressure wounds, discomfort and the use of restraints. Other studies have found that people with advanced dementia who live in a nursing home who have a feeding tube frequently have to be transferred to the hospital’s emergency room due to feeding tube-related complications.
The AGS recommends that physicians and other health care providers should discuss the benefits and problems of tube feeding with the demented person’s family or caregiver prior to the procedure. Some situations may make the use of a short-term feeding tube appropriate as well as consistent with the loved one’s wishes and values. “In these cases, clear goals of therapy should be decided before tube feeding is initiated and should be reviewed frequently,” the AGS stated.
The AGS also calls for efforts that enhance oral feeding through changes in the environment and the creation of patient-centered approaches to feeding. “Oral feeding may be one of few remaining pleasures and a time for socialization for a person with advanced dementia,” the AGS stated. “Mealtime must be regarded as an event of importance, instead of a task that needs to be completed as soon as possible.” Therefore, it’s important for the dining environment to be clutter-free as well as free of background noises. Diets should be focused on resident preference and should include adequate fluids in order to enhance the taste of the meals. The AGS recommends that trained staff members who can provide continued careful hand feeding should be an accepted alternative to tube feeding.
When people with advanced dementia lose their appetite or experience weight loss, difficulty with swallowing or aspiration, physicians and medical staff should discuss issues related to feeding as soon as possible with family members and caregivers. The AGS recommends a multidisciplinary assessment of reversible causes that might make eating difficult as well as discussions with family members about the care plan as it relates to the specific stage of dementia.
The AGS also recommends that tube feeding be considered a medical therapy that can be determined by a patient’s surrogate decision-maker based on advance directives, previously state wishes or the patient’s perceived wishes. Furthermore, all members of the health care team in long-term care settings need to understand these wishes regarding tube feeding and incorporate these preferences into the care plan.
To that end, the AGS also recommends that hospitals, nursing homes and other care settings should encourage choice as well as shared and informed decision-making related to feeding. Patient preference regarding tubal feeding should be honored and the institution shouldn’t exert pressure on the person with dementia, their family or their caregivers to use a feeding tube.
Primary Sources for This Sharepost:
American Geriatrics Society. (2013). Feeding tubes in advanced dementia position statement.