Tube feeding in patients with late stage dementia and dysphagia

Reasons for tube feeding When it becomes very difficult to feed patients with advanced dementia often tube feeding may be implemented to provide the individual with adequate nutrition (McNamara & Kennedy, 2001).
There is much debate surrounding the initiation of tube feeding and there are pros and cons that accompany both options.
Risks and benefits Groher and Crary (2010 p.311) note the risks and benefits of gastrostomy feeding.
Risks include:

· Surgery, as this is required for placement.

· Site care is needed to prevent infection.

· There is a risk of the tube becoming displaced.

· The individual can experience reflux if the food/food substitute is given too quickly and the stomach subsequently fills too quickly.

The benefits are:

· It can be used long term.

· The tube can be removed or replaced fairly easily.
It is thought that providing nutrition via tube feeding, not only prevents malnutrition and subsequent weight loss but reduces the incidence of skin breakdown and development of pressure sores and reduces the risk of aspiration (McNamara & Kennedy, 2001). However, it has been found that there is no data to suggest this is the case. In addition to this, patients generally continue to lose weight despite receiving adequate calories through their tube feeds (Huffman,2000).
There is no literature that indicates prolonged survival in patients with advanced dementia (Huffman, 2000). In fact a large study that was carried out showed no difference in survival rates between individual who ate orally and those who were tube-fed.

With regard to quality of life, which tube-feeding should ideally improve, due to adequate nutrition and the subsequent benefits of this. This may not be the case. Restraints are commonly used on tube-fed patients with advanced dementia, (Huffman, 2000) which is counter intuitive to the goal of increasing quality of life. In addition to this, data shows that tube-feeding does not improve patient comfort levels and reduces the amount of human contact the patient recieves (Huffman, 2000). The benefits of tube feeding are uncertain. Finucane, Christmas & Travis (1999) searched through research performed in this area to see whether tube-feeding can prevent aspiration pneumonia, reduce the risk of pressure sores, improve function, prolong survival or improve comfort levels. They found no published, randomised trials that compared oral feeding with tube feeding to prove or disprove these benefits.
Curran and Wattis (2004) believe there is adequate evidence illustrating that artificial feeding is associated with an increased incidence of aspiration.

Patient PreferenceThe majority of the time this is unable to be obtained as it is often suggested at a late stage, by which time the patient is unable express their wishes (McNamara & Kennedy, 2001).


Advance Directives

An advance directive can be put in place while an individual is still competent to make decisions, so they can make their wishes known, should they be incapable in the future to make decisions due to mental incapacity or being in an unconscious state (Groher & Crary, 2010 p.309). There are two parts to the advance directive. One is a ‘living will’ which is a written document, instructing health professionals to forego some type of treatment and giving them consent to do this.
The other part is the ‘durable power of attorney for health care’, where the individual appoints a person to act on their behalf should they be in a state in future where they are unable to make decisions about their medical treatment (Groher & Crary, 2010 p.309). This would enable them to say whether or not they would want nutrition provided for them via a feeding tube to sustain life.

Ethics


Ethical decision making surrounding such treatments as tube feeding when the individual concerned is unable to make the decision for themselves involves balancing all factors (Groher & Crary, 2010 p.309). Morals and values of society and individuals are considered as well as evidence based medical facts and legal precedence.

Below are the links for ethics policies from the NZSTA and Auckland DHB


http://www.adhb.govt.nz/CETU/IMGs/Legislation&Ethics.htm
http://www.speechtherapy.org.nz/about-nzsta/ethics