DECEMBER 18, 2000 VOLUME 8, NUMBER 25
Frail, demented nursing home patients can eventually lose the ability to take food and fluids by mouth. When that process begins to occur tube feedings may be started. Doctors and family members may believe that such feedings prolong life and improve the ability to fight bedsores and disease. Dr. Thomas Finucane, a nationally recognized expert practicing Geriatric Medicine at Johns Hopkins in Baltimore, challenges that easy assumption. In a report for Elder Law Issues, Dr. Finucane explains:
Although it seems implausible, when faced with an emaciated, demented, permanently recumbent, poorly communicative patient with bedsores who is losing weight, clinicians and loved ones should remember there is no good evidence that administering tube feeding will help this patient.
Randomized trials are the gold standard for evaluating whether treatments are effective. Such trials are generally lacking with respect to tube feeding. Other data, some quite persuasive, have been developed, and these studies are virtually unanimous in showing lack of effectiveness.
Several lines of evidence suggest that tube feeding will not prolong survival when compared to a conscientious effort at hand feeding. Death rates are very high in the days and months after feeding tubes are placed.
No published paper suggests that tube feeding will reduce the risk of aspiration pneumonia; several trials find feeding tubes to be risk factors for the development of pneumonia. Aspiration pneumonia usually arises from inadvertent inhalation of either contaminated oral secretions or of regurgitated gastric contents. Tube feeding could not be expected to prevent either of these events.
Pressure sores have not been shown to improve when tube feeding is given. Once feedings are initiated, patients will produce more urine and stool, which are definite risk factors for pressure sores.
Risk of infection has not been reduced among tube fed patients. Serious and fatal infections have been shown to result from tube feeding.
Demented patients have not been shown to get stronger and function better with tube feeding.
Although it is difficult to know the experience of a noncommunicative person, there is no evidence that tube feeding reduces suffering. Restraints are more often used in tube fed patients.
Dozens of serious side effects have been reported as a result of tube feeding. Based on these data, it seems that tube feeding is overused in the care of patients with advanced dementia.
Legal battles over tube feeding have focused on comparing the benefits and burdens of the procedure. Benefits have been assumed, and burdens have usually been limited to the physical pain associated with insertion of tubes. Dr. Finucane challenges both sets of assumptions. He also challenges the medical community to undertake research to determine whether tube feedings really are beneficial.
Dr. Finucane’s analysis of medical studies, “Tube Feeding in Patients With Advanced Dementia,” was published in the Journal of the American Medical Association. Read the abstract or order his paper at http://jama.ama-assn.org/issues/v282n14/abs/jsc90078.html