Feeding tubes are used to provide liquid nutrition for individuals who have difficulty chewing and/or swallowing or who are completely unable to eat on their own. The decision to use a feeding tube is often a complex one, especially for senior patients. Family members may find themselves responsible for choosing on behalf of their aging loved ones whether to use a tube, but sometimes the information they receive from medical professionals is not entirely accurate.
Types of Feeding Tubes
There are several different kinds of feeding tubes that are used for different reasons. The two general categories are nasal tubes, which enter through the nose, and abdominal tubes, which enter through the skin of the abdomen. Both nasal tubes and abdominal tubes may end in either the stomach (known as gastric or G-tubes) or in the small intestine (known as jejunal or J-tubes), depending on where liquid nutrition must be deposited. In some cases, a person may not be able to tolerate food and medication being introduced directly to the stomach, therefore a J-tube is preferable.
Nasal feeding tubes are typically used for short-term tube feedings while a person heals and their ability to eat safely improves. Their use for longer than a couple of weeks can cause severe irritation and injury to the tissues of the throat and esophagus. Abdominal feeding tubes are typically placed for long-term or permanent use. However, both temporary and permanent feeding tubes can be removed if a patient regains the ability to eat and drink on their own.
Why Are Feeding Tubes Necessary?
There are many reasons why people of all ages may require a feeding tube either temporarily or permanently. Certain head, neck and esophageal cancers can prevent patients from eating normally, as can head trauma, traumatic brain injuries, stroke and neurological disorders like dementia and Parkinson’s disease. Feeding tubes may also be recommended for individuals who refuse to eat and have become malnourished.
Family members of seniors who have advanced dementia, such as Alzheimer’s disease, are often urged to consider feeding tube placement. This is usually because late-stage dementia patients develop a condition called dysphagia, where they lose the ability to chew and swallow safely. In addition to ensuing undernutrition, dysphagia increases the risk of aspirating food or drink and developing pneumonia, a serious lung infection that can be fatal.
In other cases, a feeding tube may be required if a person has been placed on a ventilator to help them breathe. Use of a ventilator often requires a surgical procedure called a tracheostomy to create a surgical airway in the trachea. A tube called a trach tube is placed in this opening to clear secretions in the lungs, but the trach tube also prevents a patient from taking food and drink by mouth.
The Controversy Over Artificial Nutrition and Hydration at the End of Life
For many seniors who are not conscious or mentally capable of making their own health care decisions, the choice to use a feeding tube typically falls to their health care power of attorney or guardian. The idea of a loved one no longer eating or drinking is disturbing for most people to consider, especially because it is their responsibility to make the best possible care decisions and minimize discomfort. However, the placement of a feeding tube is not a simple fix that is free of complications or risks.
A type of abdominal tube called a percutaneous endoscopic gastrostomy or PEG tube (named for the procedure used to place it) is usually what medical professionals recommend, especially for patients with late-stage dementia who can no longer eat or refuse to do so. Placement of the tube is not particularly difficult or risky, but complications may arise from the incision and its ongoing use.
PEG tubes are meant to prevent aspiration, minimize the risk of pneumonia, increase nutritional intake and help fortify the immune system to promote healing and functionality, but research has failed to show that such aggressive intervention delivers these benefits. Infection and leaking of the surgical site are concerns, and aspiration is still a possibility. Furthermore, a patient may need to be physically or chemically restrained to prevent them from forcibly pulling out their feeding tube.
Disinterest in or refusal of food and drink are common symptoms at the end of life, regardless of what health conditions are present. This is a natural step in the progression towards death as the body begins to minimize normal processes like digestion. In fact, consumption of food and fluids may even cause discomfort for some terminal patients.
The best alternative to tube feeding for seniors with severe dementia is careful hand feeding. During this process, trained aides will offer food that is typically pureed and/or thickened and read a patient’s verbal and nonverbal cues to determine whether they are hungry, thirsty or experiencing any discomfort. Hand fed patients are carefully observed to prevent aspiration and are not forced to eat or drink if they do not show any interest in the process. Family members can also participate in hand feeding, which adds a valuable social component to meal times.
Unlike tube feeding, hand feeding is a time-consuming process that requires total supervision. Doctors at skilled nursing facilities and hospitals may overstate the benefits of feeding tube placement because this option is easier and faster for staff members to handle.
The Decision to Place a Feeding Tube
Thoroughly discussing the pros, cons and alternatives to any medical decisions takes time and effort for medical professionals and families. Feeding tubes of all kinds certainly serve an important purpose, primarily for individuals who are not in the late stages of an untreatable illness. Unfortunately, tube feeding is not beneficial for all patients who cannot eat or who refuse to eat.
This is just one important end-of-life issue that many seniors and caregivers face. It is crucial for families to discuss preferences for end-of-life care and put them in writing early on to avoid confusion and ensure one another’s wishes are respected. Living wills and advance directives like do-not-resuscitate (DNR) orders and physician orders for life sustaining treatment (POLST) forms are vital for recording end-of-life care choices.
Ultimately, choosing whether to elect tube feeding for oneself or as an advocate for someone else is not an easy task. Working closely with the health care team is the best way to gain a complete understanding of the difficult ethical principles and medical options at hand.