Tube feeding -'The times they are a changin'...

Last month, a task-force of gastroenterologists published an excellent review article on tube-feeding in a major GI journal, Gastrointestinal Endoscopy.  (DeLegge MH, McClave SA, DiSario JA, Baskin WN, Brown RD, Fang JC, Ginsberg GG . Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.  Gastrointest. Endo.  2005; 62(6): 952-959) I was honored to be asked to write an accompanying editorial, which is available free at: http://journals.elsevierhealth.com/periodicals/ymge  (Unfortunately, the far more important review article is not free, but may be ordered or available through your medical library.)  In recent years, a number of studies, well referenced in the review, have demonstrated little or no benefit for tube feeding for many patient groups with advanced illness.  Most specifically, studies have generally failed to demonstrate a benefit for tube feeding in patients with advanced dementia by almost any measurable criteria – length of life, quality of life, or prevention of aspiration pneumonia.  Those of us working and writing about tube feeding in the field of palliative care have taken a fair bit of flack on this issue for understandable reasons.  Feeding and nurturing are at the core of our basic human values.  Legitimate ethical controversies exist regarding when to start and stop artificial feeding.  However, I believe these debates will best be served if they are informed by a thoughtful review of available evidence, as provided in the task-force's article.  While many of the findings in this review will not surprise professionals working in hospice or palliative care, the importance of the review is that it was performed by gastroenterologists and reflects, I think, some serious soul-searching on their part.  If, as available (but admittedly far from perfect) evidence suggests, there is limited utility for tube feeding for patients with many chronic illnesses such as advanced dementia, what implications does this have for gastroenterologists, who are often asked to insert these tubes?  Are gastroenterologists just technicians, whose job is to insert tubes?  Do they have any professional or moral responsibility to comment on whether tube feeding will likely help patients, families and clinicians meet certain goals of care?  I suggest in my editorial that the answer to this latter question must be, yes.  Probably a Freudian slip, but in the text of my editorial I mistakenly wrote, “Periprocedure morbidity and morality of PEG-tube placement appears to be a minor factor in most cases, as the investigators suggest.”  Of course, I meant periprocedure mortality, which is indeed usually a minor concern.  Periprocedure morality should never be a minor factor. 

I view the publication of this article optimistically.  The task-force is really to be commended for taking the issue on.  I also see as a good sign the journal’s kind invitation to ask a palliative medicine physician to write an accompanying editorial.  This is a sign our growing acceptance as a medical specialty.  Yessir, the times they are a changin’ and in this case for the better.

Comments

[Mia Adams]

Very timely post. I just sent a patient with Parkinson's to the ICU tonight after she aspirated on tube feeds that had been administered via a peg tube. Other than dementia, are there other diagnoses that have been researched in terms of the efficacy and safety of tube feeds?

[Judy]

I know this if off the topic. I have a question I thought you might be able to help me with.
Are you familiar with a case where an opioid was was unintentionally administered at a very high dose, opioid was titrated down and patient survived....maybe even awakened and later died comfortably.

Judy