TUBE FEED OR NOT TO FEED? A Palliative Care Physician’s perspective on artificial hydration and nutrition

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TUBE FEED OR NOT TO FEED? A Palliative Care
Physicians perspective on artificial hydration
and nutrition

• James Hallenbeck, MD
• Director, Palliative Care Services
• VA Palo Alto HCS

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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
  Alzheimers disease and recurrent aspiration
  pneumonia
• C) A patient with Parkinsons
  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?
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What do you say when asked
Doctor, shes loosing so much weight. Do you
think we should put in a tube or something
Hes aspirating. Well need a PEG tube.
You cant just let her starve to death!
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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

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Artificial Nutrition and HydrationDifficult
Decisions
What 'ingredients' go into making these decisions?
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Relevant Factors

• Effect on life expectancy
• Effect on quality of life
• Values/Belief systems
• Patients (may or may not be known)
• Family
• Clinical staff (physicians, nurses, speech
  therapists etc.)
• Social/cultural belief systems
• Healthcare system
• Effect on workload
• Effect on reimbursement
• Fear of recrimination
• Ethical/Legal/Policy Concerns

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Life Prolongation What is the Evidence?

Strongest
Weakest
Acute, catabolic illness
Advanced, terminal illness Dementia, Cancer
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Life Enhancement What is the Evidence?
Weakest
Strongest
Patients with no hunger, poor base-line
functional status, terminally ill
Patients with hunger, good functional status,
mechanical barrier to eating
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Who gets PEG tubes?
N 7369

• Top three categories
• 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.
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Prospective Cohort Study on Dementia
N99
Of 99 patients hospitalized with advanced
dementia

• Tube Placement
• 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.
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? 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)

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? 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.
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What about Quality of Life?Limited data
N150
Community Prospective Cohort Study

• 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.
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Cancer and Artificial Nutrition
Two separate issues Mechanical blockage or
inability to eat Cancer cachexia/anorexia syndrome
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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

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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

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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!

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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?
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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.
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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 patients condition
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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

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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