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Assisted oral feeding is preferred approach
Once persistent eating difficulties arise in a patient with advanced dementia, caregivers are confronted with a heart-wrenching decision: Should a feeding tube be placed?
"Naturally, people want their family members to be comfortable. From the beginning of life, we have learned to associate food with comfort and nurturing," says Caroline A. Vitale, MD, AGSF, director of the Geriatric Medicine Fellowship Program at the University of Michigan Health System in Ann Arbor.
It would be logical to assume that the nutrients provided by artificial feeding would increase comfort, energy levels and even length of life. "However, for older people with advanced dementia, this type of feeding can often have the opposite of the desired effect," says Vitale.
In fact, research shows that feeding tubes can be associated with agitation, ileus, increased propensity for emergency department visits due to tube malfunction, increased risk of pressure ulcers, and increased use of physical and chemical restraints, without improving functional status or quality of life.1,2
In light of this growing body of evidence, The American Geriatrics Society (AGS) released an updated position statement in July 2014 on the use of feeding tubes in advanced dementia patients.3 "The statement advocates for careful assisted oral feeding as tolerated, as the preferred approach in patients with advanced dementia," says Vitale, vice chair of the AGS’ Ethics Committee.
The position statement was first published in 1993, and updated in 2005. "This time, our efforts were focused on updating this same position statement to reflect the publication of several recent studies elucidating the disease trajectory of advanced dementia and detailing treatment burdens associated with tube feeding in such patients," says Vitale.
There is a growing acceptance of palliative approaches to care in non-cancer conditions with poor prognoses, including advanced dementia. "Overall, the AGS position statement advocates for a palliative approach to care when eating problems arise in patients with advanced dementia," says Vitale.
Any aggressive nutrition intervention requires the practitioner to consider two important principles, says Ronni Chernoff, PhD, RD, FADA, director of the Arkansas Geriatric Education Center and professor in the Reynolds Department of Geriatrics at University of Arkansas for Medical Sciences in Little Rock. These are, "First, do no harm," and, "What would the patient want?"
"It appears that dementia patients do well when hand-fed. But that is time-consuming and labor-intensive," says Chernoff.
Technology has made it easier to use feeding tubes. "We know that about one-third of U.S. nursing home residents with advanced dementia have them," says Vitale.
Clear objectives should be determined before instituting tube feedings for any patients, says Chernoff, but particularly in patients with advanced dementia who may be impaired in their ability to express their wishes.
"Not only is it hard to see what benefits are derived from artificially feeding terminally demented patients, but the risks associated with tube feeding might make it somewhat dangerous," she adds.
Perhaps the greatest ethical consideration is the principle of autonomy, says Chernoff. Decisions about nutrition and hydration are legally considered medical interventions, as are other life support methods, and should be based on patient preferences.
"Every effort must be made to uncover what the patient would want," says Chernoff.
Ronni Chernoff, PhD, Director, Arkansas Geriatric Education Center, Little Rock, AR. Phone: (501) 603-1964. Fax: (501) 603-1966. Email: ChernoffRonni@uams.edu.
Caroline A. Vitale, MD, AGSF, Director, Geriatric Medicine Fellowship Program, University of Michigan Health System, Ann Arbor. Phone: Phone: (734) 845-3072. Fax: (734) 936-1884. Email: firstname.lastname@example.org.