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Tube feeding patients with advanced dementia: an ethical dilemma

Published online by Cambridge University Press:  28 February 2007

Edel P. McNamara  and
Nicholas P. Kennedy
Edel P. McNamara*
Affiliation:
Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Republic of Ireland
Nicholas P. Kennedy
Affiliation:
Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Republic of Ireland
*
*Corresponding Author: Edel McNamara, fax +353 1 4542043, email [email protected]
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Abstract

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Many patients with dementia lose the ability to feed themselves in the advanced stages of the disease. Tube feeding is sometimes initiated to overcome feeding difficulties. Recent studies have questioned the appropriateness of tube feeding in these patients. There is limited research to support the benefits of enteral nutrition in patients with advanced dementia. Deciding whether to tube feed or to withhold tube feeding from a patient with dementia poses a difficult challenge, and many carers may make decisions without adequate information and with an overly hopeful view of the future clinical course. Numerous studies have examined opinions about life-sustaining treatments; many individuals do not want to be tube fed if they were to develop dementia. Results from studies examining the opinions of physicians and other health professionals regarding the use of tube feeding in these patients are conflicting. A number of factors, such as race and cultural background may affect decisions. Healthcare professionals, relatives and patients must be aware of the realistic expectations of tube feeding in patients with dementia, as it can be difficult to withdraw once it has been initiated.

Keywords

DementiaTube feedingEthics
Type
Postgraduate Symposium
Information
Proceedings of the Nutrition Society , Volume 60 , Issue 2 , May 2001 , pp. 179 - 185
Copyright
Copyright © The Nutrition Society 2001

References

Berlowitz, DR, Ash, AS, Brandeis, GH, Brand, HK, Halpern, JL & Moskowitz, MA (1996) Rating long-term care facilities on pressure ulcer development: importance of case-mix adjustment. Annals of Internal Medicine 124, 557–563.CrossRefGoogle ScholarPubMed
Berlowitz, DR, Brandeis, GH, Anderson, J & Brand, HK (1997) Predictors of pressure ulcer healing among long-term care residents. Journal of the American Geriatrics Society 45, 30–34.CrossRefGoogle ScholarPubMed
Callahan, CM, Haag, KM, Buchanan, NN & Nisi, R (1999) Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting. Journal of the American Geriatrics Society 47, 1105–1109.CrossRefGoogle Scholar
Carmel, S (1999) Life-sustaining treatments: what doctors do, what they want for themselves and what elderly persons want. Social Science Medicine 49, 1401–1408.CrossRefGoogle ScholarPubMed
Carmel, S & Mutran, EJ (1999) Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments. Social Science and Medicine 49, 303–311.CrossRefGoogle ScholarPubMed
Clare, AW (1990) Psychological medicine. In Clinical Medicine, pp. 965–1000 [Kumar, P and Clark, M, editors]. London: WB Saunders.Google Scholar
Cogen, R, Patterson, B, Chavin, S, Cogen, J, Landsberg, L & Posner, J (1992) Surrogate decision-maker preferences for medical care of severely demented nursing home patients. Archives of Internal Medicine 152, 1885–1888.CrossRefGoogle ScholarPubMed
Cranford, RE & Ashley, BZ (1986) Ethical and legal aspects of dementia. Neurological Clinics 4, 479–490.CrossRefGoogle ScholarPubMed
Cusack, D (2000) Autonomy and consent. In Medical Ethics and the Future of Healthcare, pp. 90–99 [Kearon, K and O'Farrell, F, editors]. Dublin: The Columbia Press.Google Scholar
Danis, M, Southerland, L, Garrett, J, Smith, J, Hielman, F, Pickard, G, Egner, D & Patrick, D (1991) A prospective study of advanced directives for life-sustaining care. New England Journal of Medicine 324, 882–888.CrossRefGoogle ScholarPubMed
Department of Health and Children (1999) District/community hospitals and extended care. Health Statistics 1999, pp. 190–200. Dublin: The Stationery Office.Google Scholar
Elia, M, Micklewright, A, Shaffer, J, Wood, S, Russell, C, Wheatley, C, Scott, D, Johns, A, Thomas, A, Holden, C, Baldwin, C & Meadows, N (1999) The 1998 Annual Report of the British Artificial Nutrition Survey. Maidenhead, Berks.: British Association of Parenteral and Enteral Nutrition.Google Scholar
Emanuel, L, Barry, M, Stoeckle, J, Ettleson, L & Emanuel, E (1991) Advanced directives for medical care – a case for greater use. New England Journal of Medicine 324, 889–895.CrossRefGoogle ScholarPubMed
Evans, DA, Funkenstein, HH, Albert, MS, Scherr, PA, Cook, NR, Chown, MJ, Herbert, LE, Hennekens, CH & Taylor, JO (1989) Prevalence of Alzheimer's disease in a community population of older persons higher than previously reported. Journal of the American Medical Association 262, 2551–2556.CrossRefGoogle Scholar
Finucane, TE (1995) Malnutrition, tube feeding and pressure sores: data are incomplete. Journal of the American Geriatrics Society 43, 447–451.CrossRefGoogle ScholarPubMed
Finucane, TE & Bynum, JP (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 348, 1421–1424.CrossRefGoogle ScholarPubMed
Finucane, TE, Christmas, C & Travis, K (1999) Tube feeding in patients with advanced dementia: a review of the evidence. Journal of the American Medical Association 282, 1365–1370.CrossRefGoogle ScholarPubMed
Garrett, JM, Harris, RP, Norburn, JK, Patrick, DL & Danis, M (1993) Life-sustaining treatments during terminal illness: who wants what? Journal of General Internal Medicine 8, 361–368.CrossRefGoogle Scholar
Gerety, MB, Chiodo, LK, Kanten, DN, Tuley, MR & Cornell, JE (1993) Medical treatment preferences of nursing home residents: relationship to function and concordance with surrogate decision-makers. Journal of the American Geriatrics Society 41, 953–960.CrossRefGoogle ScholarPubMed
Gjerdingen, DK, Neff, JA, Wang, M & Chaloner, K (1999) Older persons' opinions about life-sustaining procedures in the face of dementia. Archives of Family Medicine 5, 421–425.CrossRefGoogle Scholar
Goldstein, M & Fuller, JD (1994) Intensity of treatment in malnutrition: the ethical considerations. Primary Care 21, 191–206.CrossRefGoogle ScholarPubMed
Hanson, LC & Rodgman, E (1996) The use of living wills at the end of life: a national study. Archives of Internal Medicine 156, 1018–1022.CrossRefGoogle ScholarPubMed
Hasan, M, Meara, RJ, Bhowmick, BK & Woodhouse, K (1995) Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals. Gerontology 41, 326–331.CrossRefGoogle ScholarPubMed
Hodges, MO, Tolle, SW, Stocking, C & Cassel, CK (1994) Tube feeding. Internists' attitudes regarding ethical obligations. Archives of Internal Medicine 154, 1013–1020.CrossRefGoogle ScholarPubMed
Kaw, M & Sekas, G (1994) Long-term follow-up of consequences of percutaneous endoscopic gastrostomy tubes in nursing home patients. Digestive Diseases and Sciences 39, 738–743.CrossRefGoogle ScholarPubMed
Kellogg, FR, Crain, M, Corwin, J & Brickner, PW (1992) Life-sustaining interventions in frail elderly persons. Talking about choices. Archives of Internal Medicine 152, 2317–2320.CrossRefGoogle ScholarPubMed
Krynski, MD, Tymchuk, AJ & Ouslander, JG (1994) How informed can consent be? New light on comprehension among elderly people making decisions about enteral tube feeding. Gerontologist 34, 36–43.CrossRefGoogle ScholarPubMed
Lipman, T (1996) Ethics and nutrition support. Nutrition in Clinical Practice 11, 241–242.CrossRefGoogle ScholarPubMed
MacFie, J (1996) Ethical implications of recognizing nutritional support as a medical therapy. British Journal of Surgery 83, 1567–1568.CrossRefGoogle ScholarPubMed
Mebane, E, Oman, R, Kroonen, L & Goldstein, M (1999) The influence of physician race, age and gender on physician attitude toward advance care directives and preference for end-of-life decision-making. Journal of the American Geriatrics Society 47, 579–591.CrossRefGoogle ScholarPubMed
Mehr, D (1984) Feeding the demented elderly (letter). New England Journal of Medicine 311, 1383.Google Scholar
Meyers, RM & Grodin, MA (1991) Decision making regarding the initiation of tube feedings in the severely demented elderly: a review. Journal of the American Geriatrics Society 39, 526–531.CrossRefGoogle ScholarPubMed
Mitchell, SL, Berkowitz, RE, Lawson, FM & Lipsitz, LA (2000) A cross-national survey of tube-feeding decisions in cognitively impaired older persons. Journal of the American Geriatrics Society 48, 391–397.CrossRefGoogle ScholarPubMed
Mitchell, SL, Kiely, DK & Lipsitz, LA (1997) The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine 157, 327–332.CrossRefGoogle ScholarPubMed
Mitchell, SL & Lawson, FM (1999) Decision-making for long-term tube-feeding in cognitively impaired elderly people. Canadian Medical Association Journal 160, 1705–1709.Google ScholarPubMed
Morley, JE (1996) Dementia is not necessarily a cause of undernutrition. Journal of the American Geriatrics Society 44, 1403–1409.CrossRefGoogle Scholar
Norberg, A, Hirschfeld, M, Davidson, B, Davis, A, Lauri, S, Lin, JY, Phillips, L, Pittman, E, Vander Laan, R & Ziv, L (1994) Ethical reasoning concerning the feeding of severely demented patients: an international perspective. Nursing Ethics 1, 3–13.CrossRefGoogle ScholarPubMed
O'Brien, LA, Grisso, JA, Maislin, G, LaPann, K, Krotki, KP, Greco, PJ, Siegert, EA & Evans, LK (1995) Nursing home residents' preferences for life-sustaining treatments. Journal of the American Medical Association 274, 1775–1779.CrossRefGoogle ScholarPubMed
O'Mahony, D & McIntyre, AS (1995) Artificial feeding for elderly patients after stroke. Age and Aging 24, 533–535.CrossRefGoogle ScholarPubMed
Peck, A, Cohen, CE & Mulvihill, MN (1990) Long-term enteral feeding of aged demented nursing home patients. Journal of the American Geriatrics Society 38, 1195–1198.CrossRefGoogle ScholarPubMed
Post, SG & Whitehouse, PJ (1995) Fairhill guidelines on ethics of the care of people with Alzheimer's disease: a clinical summary. Journal of the American Geriatrics Society 43, 1423–1429.CrossRefGoogle ScholarPubMed
Priefer, BA & Robbins, J (1997) Eating changes in mild-stage Alzheimer's disease: a pilot study. Dysphagia 12, 212–221.CrossRefGoogle ScholarPubMed
Quill, TE (1989) Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital. Archives of Internal Medicine 149, 1937–1941.CrossRefGoogle Scholar
Rabeneck, L, McCullough, LB & Wray, NP (1997) Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 349, 496–498.CrossRefGoogle ScholarPubMed
Rabeneck, L, Wray, NP & Petersen, NJ (1996) Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. Journal of General Internal Medicine 11, 287–293.CrossRefGoogle ScholarPubMed
Reilly, RB, Teasdale, TA & McCullough, LB (1994) Projecting patients' preferences from living wills: an invalid strategy for management of dementia with life-threatening illness. Journal of the American Geriatrics Society 42, 997–1003.CrossRefGoogle ScholarPubMed
Rudberg, MA, Egleston, BL, Grant, MD & Brody, JA (2000) Effectiveness of feeding tubes in nursing home residents with swallowing disorders. Journal of Parenteral and Enteral Nutrition 24, 97–102.CrossRefGoogle ScholarPubMed
Sheiman, SL (1996) Tube feeding the demented nursing home resident. Journal of the American Geriatrics Society 44, 1268–1270.CrossRefGoogle ScholarPubMed
Sheiman, SL & Pomerantz, JD (1998) Tube feeding in dementia: a controversial practice. Journal of Nutrition, Health and Aging 2, 184–189.Google ScholarPubMed
Suski, NS & Nielsen, CC (1989) Factors affecting food intake of women with Alzheimer's type dementia in long-term care. Journal of the American Dietetic Association 89, 1770–1773.CrossRefGoogle ScholarPubMed
Van Rosendaal, GM, Verhoef, MJ & Kinsella, TD (1999) How are decisions made about the use of percutaneous endoscopic gastrostomy for long-term nutritional support? American Journal of Gastroenterology 94, 3225–3228.CrossRefGoogle ScholarPubMed
Van Rosendaal, GM, Verhoef, MJ, Mace, SR & Kinsella, TD (1997) Decision-making and outcomes for percutaneous endoscopic gastrostomy: a pilot study. Journal of Clinical Gastroenterology 24, 71–73.CrossRefGoogle ScholarPubMed
Volicer, L, Rheaume, Y, Brown, J, Fabiszewski, K & Brady, R (1986) Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type. Journal of the American Medical Association 256, 2210–2213.CrossRefGoogle Scholar
Volicer, L, Seltzer, B, Rheaume, Y, Fabiszewski, K, Herz, L, Shapiro, R & Innis, P (1987) Progression of Alzheimer's type dementia in institutionalised patient: a cross sectional study. Journal of Applied Gerontology 6, 83–94.CrossRefGoogle Scholar
Von Preyss-Friedman, SM, Uhlmann, RF & Cain, KC (1992) Physicians' attitudes toward tube feeding chronically ill nursing home patients. Journal of General Internal Medicine 7, 46–51.CrossRefGoogle ScholarPubMed
Wang, SY, Fukagawa, N, Hossain, M & Ooi, WL (1997) Longitudinal weight changes, length of survival, and energy requirements of long-term care residents with dementia. Journal of the American Geriatrics Society 45, 1189–1195.CrossRefGoogle ScholarPubMed
Watson, R (1994) Practical ethical issues related to the care of elderly people with dementia. Nursing Ethics 1, 151–162.CrossRefGoogle Scholar
Watts, DT, Cassel, CK & Hickam, DH (1986) Nurses' and physicians' attitudes toward tube-feeding decisions in long-term care. Journal of the American Geriatrics Society 34, 607–611.CrossRefGoogle ScholarPubMed
Wrigley, (1995) Mental health legislation and the care of people with dementia. Irish Journal of Psychological Medicine 12, 4–5.CrossRefGoogle Scholar