The suggested treatment of patients with advanced dementia who have difficulty eating or swallowing is often enteral tube feeding. This has been thought to prevent aspiration pneumonia, pressure ulcers and malnutrition, and has been considered to be a part of “comfort care” for the patient. Tube feeding has also been proposed as a means of improving patient survival and functional status. Finucane and colleagues reviewed the literature to determine if these suppositions were true. A MEDLINE search (1966 through March 1999) revealed no randomized, controlled trials that addressed these issues. Therefore, the authors compiled a summary of the available data and addressed the specific indications for and presumed benefits of initiating enteral tube feeding in patients with advanced dementia who are having difficulty eating.
Aspiration pneumonia is defined as a pulmonary infection after aspiration of pharyngeal secretions, as well as a self-limited pneumonitis that resolves without antibiotic therapy. No data were found that support the use of enteral tube feeding in the prevention of oral secretion aspiration or regurgitation (and subsequent aspiration) of stomach contents. Several case-control studies suggest, however, that tube feeding was a risk factor for pneumonia and death. The authors noted that enteral tube feeding does not prevent aspiration pneumonia. Malnutrition in patients with advanced dementia may be reflected in low serum albumin levels, low total lymphocyte count, decreased body mass index and impaired immune status. Providing improved nourishment through an enteral feeding tube would seem to reverse some of these findings, but the literature review does not support this supposition. Most patients continued to lose weight, and marasmic malnutrition continued despite the provision of adequate calories and protein through the feeding tube.
It remains unclear if improving the clinical markers of nutrition by tube feeding actually improves outcomes. The nutritional benefits that may accrue are likely to be offset by the adverse effects of tube feeding. The assertion that enteral tube feeding prolongs survival in patients with advanced dementia is not supported in the literature. One large study showed no difference in survival rates between demented and nondemented patients in a long-term care facility who were hand fed. Other studies show that survival in tube-fed patients is about 7.5 months after percutaneous endoscopic gastrostomy (PEG) tube placement. Pressure ulcers are thought to be prevented, or to heal, with provision of improved nourishment through a PEG tube. This supposition has not been found to be the case. Tube-fed patients may produce more urine and stool, and therefore be at higher risk of developing pressure ulcers. In addition, restraints are more commonly used on patients who have PEG tubes, representing an additional risk factor for the development of pressure ulcers in these patients. The literature also reveals that tube feeding may exacerbate other infections (e.g., sinus and middle ear infections, diarrhea, cellulitis and abscess).
Data show that enteral tube feedings do not improve functional status or patient comfort levels. One study suggests that tube feedings actually increased feelings of hunger and nausea, and decreased the amount of human contact available to the patient, as well as having other adverse effects (see the accompanying table).
The authors conclude that enteral tube feeding is not an effective treatment and is associated with numerous adverse effects. They recommend a program of conscientious hand feeding as the proper treatment in patients with advanced dementia who are experiencing eating problems. In a related editorial, McCann concurs with Finucane's findings and underscores the need to keep these patients safe and comfortable, with the patient's preferences guiding the selection of diet and the amount of nourishment. If tube feeding is instituted, specific goals should be kept in mind, and periodic reviews of these goals should occur. If the goals are not met or if adverse effects occur, discontinuation of tube feeding in these patients should be considered.
editor's note: Although studiously avoiding the ethical issues surrounding enteral tube feedings in patients with advanced dementia, this review may make it somewhat easier to deal with these issues. That is, the adverse events associated with tube feeding seem to be legion, and the benefits, if any, few. If motivated, caring hand feeding is made available, families may be less likely to worry that they are causing a loved one to “starve to death.” Demedicalizing death, involving hospice at an earlier stage and helping families cope with the inevitable are far more compassionate strategies than the unproven strategy of enteral tube feeding.—g.b.h.