by Olga Rukovets
For doctors treating advanced dementia patients—a population wholly unable to advocate for its own interests—the decision of whether or not to use feeding tubes can be an especially difficult one. Last week, the American Geriatrics Society (AGS) released an updated position statement to offer some guidance on this complex issue. Published in the July 17 issue of the Journal of the American Geriatrics Society, the statement reinforces the use of careful hand feeding in place of tube feeding in this patient group whenever possible. Tube feeding, according to the paper, is associated with agitation, increased use of physical and chemical restraints, and the development of pressure ulcers.
Caroline Vitale, MD, vice chair of the AGS Ethics Committee which published the recommendations along with the AGS Clinical Practice and Models of Care Committee, said in a press statement, "Patients with advanced dementia are dependent on others for all aspects of their care, and must rely on others to make decisions about the types of care they receive. Once persistent eating difficulties arise, family caregivers are often confronted with difficult decisions that typically include whether to continue hand feeding or initiate tube feeding." However, shared decision-making between medical staff and family or caregivers can help ensure a care plan that will reflect the individual’s needs and goals, the paper states.
The AGS recommendations include:
· Careful hand feeding should be offered; for persons with advanced dementia, hand feeding is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort.
· Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feeding should be part of usual care for older adults with advanced dementia.
· A patient’s surrogate decision maker can decline or accept tube feeding as a medical therapy in accordance with advance directives, previously stated wishes, or what it is thought the patient would want.
· It is the responsibility of all members of the health care team caring for residents in long-term care settings to understand any previously expressed wishes of the patient (through review of advance directives and with surrogate caregivers) regarding tube feeding and incorporate these wishes into the care plan.
· Hospitals, nursing homes, and other care settings should promote choice, endorse shared and informed decision-making, and honor patient preferences regarding tube feeding. They should not impose obligations or exert pressure on patients or providers to institute tube feeding.
Read the full position statement from the AGS, which includes the rationale behind each of the five recommendations, here. Also, see Neurology Today’s previous coverage on the use of feeding tubes in older dementia patients: bit.ly/WqM04R.