Many individuals have tube feeding implemented in the end stages of life. It is also common to have surrogates making life support decisions for others. When family members are placed in the role of decision-maker for an incompetent patient, what factors influence life support decisions? A case study and ethnomethodological inquiry provide an in-depth understanding of factors that influenced one daughter in her decision to have tube feeding implemented for her incompetent and severely debilitated mother. The decision was difficult and constituted a time of crisis. Unfortunately, the most influential factors in decision-making were: (a) urgency in the face of impending death, (b) lack of insight into the mother's values and preferences in relation to life support through tube feeding, (c) lack of knowledge over what tube feeding involved, and (d) the belief that tube feeding would not prolong her mother's life and suffering. Nine other, less influential, factors were also found. Improving the sensitivity of health care professionals to the agony of decision-making and to the decision-making process for life support are the major focuses of this paper.

Enteral tube feeding remains an indispensible strategy to treat disease-related malnutrition. In the present study we evaluated in clinical practice whether prescribed feeding volumes correspond with administered quantities and we highlight possible causes for discrepancies. During a 4-month observation period data from all patients fully depending on tube feeding (1·5–2·5 litres/d) were collected in a Dutch 900-bed academic hospital. The range for administered feeds to be adequate was set at 100 ± 10 % of the prescribed dose. Fifty-five patients (mean age 57 (sd 30) years) were included. Tube feeding was given continuously via pump (n 37) or drip (n 3), in portions (n 14) or by combined modes (n 1). Administered tube feeding amounts were significantly lower than prescribed in 40 % of all patients (P ≤ 0·001). The mean ratio of administered v. prescribed energy was 87 (sd 21) % (all modes), 85 (sd 24) % (pump), 94 (sd 12) % (portions) and 88·3 (sd 18·1) % (drip), respectively. The mean energy deficit amounted to 1089 kJ/d (range − 7955 to +795). Only on intensive care unit wards did feeding administration meet the set goal. Feeding interruptions because of diagnostic or therapeutic procedures were the main reason for decreased intakes. Our findings show that many patients relying on tube feeding do not meet their nutritional goals during hospital stay. This problem can be addressed by adapting feeding schedules and the use of formulations with a higher energy density.