TUBE FEED OR NOT TO
FEED?
A Palliative Care Physician’s
perspective on artificial hydration and
nutrition
James Hallenbeck, MD
Director, Palliative Care Services
VA Palo Alto HCS
Pre-Test
For which of the following conditions
would you advice PEG tube placement?
A)
Complete esophageal obstruction due to
esophageal cancer in a patient with hunger.
B)
A patient with advanced Alzheimer’s disease and
recurrent aspiration pneumonia
C)
A patient with Parkinson’s disease, living at home,
who needs to be fed and yet takes a very long time to feed.
D)
A patient with stroke a week ago, who cannot eat
without choking.
What reason would you give and what
evidence supports your recommendation?
What do you say when asked…
“Doctor, she’s loosing so much
weight. Do you think we should put
in a tube or something…”
“ He’s aspirating. We’ll need a PEG tube.”
“You can’t just let her starve to
death!”
Objectives
By the end of this session you will be able to…



Cite evidence for and against the use of tube
feeding in certain situations
Discuss potential benefits and burdens with a
patient or family, incorporating this evidence
List possible advantages and disadvantages to
hydration at the end of life
Artificial Nutrition and Hydration
Difficult Decisions…
Relevant Factors
Effect on life expectancy
 Effect on quality of life
Values/Belief systems:






Healthcare system




Patients (may or may not be known)
Family
Clinical staff (physicians, nurses, speech therapists etc.)
Social/cultural belief systems
Effect on workload
Effect on reimbursement
Fear of recrimination
Ethical/Legal/Policy Concerns
Life Prolongation – What is the
Evidence?
Weakest
Advanced,
terminal illness –
Dementia, Cancer
Strongest
Acute,
catabolic
illness
Life Enhancement – What is the
Evidence?
Weakest
Patients with no
hunger, poor baseline functional
status, terminally
ill
Strongest
Patients with hunger,
good functional
status, mechanical
barrier to eating
Who gets PEG tubes?

Top three categories –






N = 7369
Organic, neurologic/dementia 28.6%
Stroke 18.9%
Head and neck cancer 15.7%
Procedural complication rate 4%
Short-term mortality 23.5% died during hospitalization
Median survival 7.5 months
Rabeneck, L., N. P. Wray, et al. (1996). "Long-term outcomes of patients
receiving percutaneous endoscopic gastrostomy tubes." J Gen Intern Med
11(5): 287-93.
Prospective Cohort Study on
Dementia
Of 99 patients hospitalized
with advanced dementia…

Tube Placement




N=99
50% received a new tube
31% left without a tube
17% came and left with a tube
Mortality



85% discharged alive
Median survival: 175 days
No survival advantage to tube feeding p=.90
Meier, D. E., J. C. Ahronheim, et al. (2001). "High short-term
mortality in hospitalized patients with advanced dementia: lack of
benefit of tube feeding." Arch Intern Med 161(4): 594-9.
? Major Predictors for Tube
Placement?

African American ethnicity (odds ratio 9.43 CI
2.1-43.2)

Residence in nursing home (odds ratio 4.9 CI
1.02-2.5)
? Tube Placement Helpful for
Preventing Aspiration Pneumonia
Croghan followed 22 dementia patients who
underwent videofluroscopy

In predicting aspiration in next 6 months
Sensitivity 65%
 Specificity 67%



No statistically significant change in aspiration
rates – tubed or not tubed
No statistical difference in mortality
Croghan, J., E. Burke, et al. (1994). "Pilot study of 12-month
outcomes of nursing home patients with aspiration on
videofluroscopy." Dysphagia 9: 141-146.
What about Quality of Life?
Limited data…
Community Prospective Cohort
Study


N=150
70% no improvement in functional status,
nutritional status, quality of life
50% mortality at one year
Callahan, C. M., K. M. Haag, et al. (2000). "Outcomes of percutaneous
endoscopic gastrostomy among older adults in a community setting." J Am
Geriatr Soc 48(9): 1048-54.
Cancer and Artificial Nutrition
Two separate issues:
Mechanical blockage or
inability to eat
Cancer cachexia/anorexia
syndrome
Mechanical Blockage/Difficulty
Eating in Cancer
Bypassing obstruction appears
indicated especially in…




Early disease states
High functional status
Hunger and thirst present
Temporary problem (ex. Severe esophagitis due
to chemotherapy and radiation
Cancer Anorexia/Cachexia
Syndrome




Mediated by tumor-associated cytokines (TNF), IL-1,
IL-6 and LIF)
Body shifts to catabolic state
Significant physiologic differences from starvation
Little evidence enteral feeding (or TPN) effective in:



Improving functional status
Other quality of life measures
Prolonging life
Ethical/Legal Concerns


Artificial feeding and hydration - medical interventions
that can be refused by a competent patient or duly
appointed and informed surrogate
States vary in their laws regarding tube feeding



Recent California case
In “non-terminally ill’, brain damaged, but not comatose
patients clear and convincing evidence of prior wishes now
required.
Tube insertion requires informed consent!
Talking with Patients and Families
about possible Artificial Nutrition
Key Principle of informed
consent:
Decision maker informed about
potential benefits and burdens and
possible alternatives.
For something like tube-feeding, are the only
relevant benefits and burdens (risks) those
related to the procedure?
So, How are Clinicians doing in
Obtaining Informed Consent?
Retrospective chart review of 154
tube placements


1/154 documented procedure-specific discussion of
benefits, burdens and alternatives.
12/33 definitely or probably competent patients signed
consent form


Surrogate signed additional 21 (despite pt being competent)
One year mortality: 50%
Brett, A. S. and J. C. Rosenberg (2001). "The
adequacy of informed consent for placement
of gastrostomy tubes." Arch Intern Med
161(5): 745-8.
Talking with Families
Families often advocate for loved-ones using
our language
What is the sub-text of a request for
artificial nutrition – usually a desire to
nurture
If recommending against artificial
nutrition/hydration, be prepared to offer
an alternative means of nurturing that is
appropriate for the patient’s condition
Hydration in Terminal Illness

Arguments for:





Minimum standard of care
? Greater comfort with hydration
? Less confusion, restlessness, neuromuscular irritability
Not clear actually prolongs life significantly
Arguments against:



? Prolong dying
Less discomfort due to decreased urine output, GI
secretions/nausea, pulmonary secretions with pneumonia
Decreased fluids act as natural anesthetics for the CNS,
natural sedation, less suffering
SUMMARY



Decisions regarding artificial nutrition and hydration
are difficult for clinicians, patients and families
The evidence base for tube feeding in advanced,
terminal illness is weak for both prolongation of life
and improved quality of life
Decision making should incorporate patient and family
values as well as informed consent regarding potential
benefits, burdens and alternatives