Tube Feeding

Tube feeding is an optional medical treatment to deliver nutrition when a patient lacks the ability to eat or swallow independently. The most common device used for long-term tube feeding in the institutionalized older population is the percutaneous endoscopic gastrostomy (PEG) tube. A PEG tube is placed directly into the stomach through a small hole in the skin during a simple procedure requiring only mild sedation and local anesthetic. A jejunostomy tube (J-tube) is similar to a PEG tube but is used less often. A J-tube delivers food into the first part of the small intestine rather than the stomach. If it is anticipated that tube feeding will be needed for less than two weeks, a temporary tube may be placed through the nose into the stomach (nasogastric tube), but this route is usually inappropriate for long-term use. Once a feeding tube is placed, commercially prepared liquid food, designed to provide a balanced diet, is delivered to the patient through the tube.

The most common reasons that tube feeding is used in U.S. nursing homes are advanced dementia (52 percent), stroke (24 percent), Parkinson’s disease (9 percent), and malignancy (7 percent) (Kaw and Sekas). In situations where the underlying condition causing the swallowing problem is potentially reversible, such as an acute stroke, the feeding tube may be indicated for only a short time. For chronic conditions where the underlying condition is unlikely to improve (e.g., dementia or Parkinson’s disease), tube feeding is a long-term intervention.

The insertion of a feeding tube is relatively safe. Although local bleeding, infection, dislodgment, or bowel perforation can occur, these complications are unusual and rarely life-threatening. More common adverse effects of tube feeding among older persons include electrolyte disturbances, diarrhea, and agitation leading to the use of restraints or administration of psychotropic medications.

Although dementia is the leading diagnostic condition for use of a feeding tube among older patients, there is limited evidence to support its use in this setting (Finucane et al.; Gillick). Eating problems generally occur at the very end stages of dementia, and the decision to initiate tube feeding rather than adopt a palliative approach can be difficult. Unfortunately, there are no randomized controlled trials of tube feeding to guide this decision. However, a review of the best available evidence failed to find an association between tube feeding and survival in the nursing home population (Mitchell and Tetroe). Data from nonrandomized studies also indicate that the placement of a feeding tube in older patients will not prevent aspiration (Finacare and Bynum). Tube feeding has not been shown to improve nutritional status, nutritional markers, or the clinical consequences of malnutrition, such as pressure ulcers in demented patients with eating problems. Finally, tube feeding has not been found to improve the comfort, functional status, or quality of life in this population.

Due to the lack of proven benefits of tube feeding, experts advocate the judicious use of hand-feeding in older patients with dementia whenever possible. For less debilitated older patients with eating problems, ethical decision-making requires weighing the potential risks and benefits of tube feeding in the specific situation with the values and preferences of the patient.