AGS Supports Evidence-Based, Patient-Centered Use of Feeding Tubes in Advanced Dementia

When the American Geriatrics Society (AGS) last updated its position statement on the use of feeding tubes in older adults with advanced dementia, emerging research was beginning to question their use. That was in 2005. Since then, a growing number of studies have concluded that the use of percutaneous endoscopic gastrostomy tube feeding in the treatment of these patients is not beneficial. In fact, research has identified significant risks associated with this treatment in this population.¹

Though intended to prevent adverse outcomes such as malnutrition, functional decline, and mortality among older patients with end-stage dementia, feeding tubes do not appear to facilitate those outcomes. Research has also failed to provide evidence that tube feeding prevents or improves the healing of pressure ulcers in these patients. And contrary to expectation, the tubes have not been found to lower risks of aspiration and pneumonia. In fact, new research suggests that tube feeding may not only increase that risk, but also causes discomfort¹ and agitation,² and leads to other complications, including the dislodgement and clogging of the tubes, which often results in emergency department visits and hospitalizations.¹ In contrast, the careful hand-feeding of patients with severe dementia has been shown to both lower risks of aspiration pneumonia and increase patient comfort.² Despite this, an estimated one-third of US nursing home residents with advanced dementia have feeding tubes.

In light of these findings, the AGS’ Ethics and Clinical Practice and Models of Care committees recently updated the society’s Feeding Tubes in Advanced Dementia Position Statement. To revise the statement, Kathryn Daniel, PhD, RN, Ramona Rhodes, MD, Caroline Vitale, MD, and Joseph Shega, MD, reviewed the latest research on the topic and expert professional recommendations regarding feeding tube use among older patients with advanced dementia.¹ Many of the studies were conducted in long-term care settings and are particularly relevant to those in these settings, notes Dr. Rhodes, who urges those who work in the field to review the new statement.

“Long-term care administrators and staff should know that studies are identifying the downsides to feeding tube placement in people with end-stage dementia,” she explains. “Administrators, staff, and healthcare providers for these patients should also know that communication with patients and caregivers is key and should involve conversations about goals of care, patients’ values and preferences, and alternatives. It’s important that caregivers not feel pressured to make a decision to allow tube placement.”

The AGS’ new position statement allows that there are certain circumstances in which providing temporary, short-term tube feeding may be appropriate, such as when a patient has had a stroke that is causing swallowing difficulty that may improve over time. In those cases, clear goals of treatment should be identified and the patient’s status should be reviewed frequently to ensure that benefits continue to exceed drawbacks.

“Some patients with other conditions may be able to resume oral nutrition at some point,” Dr. Rhodes notes. “Unfortunately, end-stage dementia is not a reversible process, and research has identified significant drawbacks to placing feeding tubes in these patients.”

Among other things, the AGS’ new statement underscores the importance of healthcare providers discussing the benefits and burdens of tube feeding with patients’ family members and other decision-makers. The statement includes the following five positions:

•     Percutaneous feeding tubes are not recommended for older adults with advanced dementia. 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. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.

•     Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feedings should be part of usual care for older adults with advanced dementia.

•     Tube feeding is a medical therapy that can be declined or accepted by a patient’s surrogate decision-maker in accordance with advance directives, previously stated wishes, or what it is thought the patient would prefer.

•     It is the responsibility of all members of the healthcare 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 to incorporate these wishes into the care plan.

•     Institutions such as 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.

The full text of the new statement—including commentary and the rationale for each of the five positions and references—is available online at www.americangeriatrics.org.

The revised guideline parallels the AGS’ recommendation regarding the use of tube feeding in adults with advanced dementia as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely^® campaign. The ABIM campaign asks leading medical organizations to identify five tests or procedures that should be performed less often than they are, and that patients should question if they are recommended. Both the AGS and the American Academy of Hospice and Palliative Medicine included tube feeding in patients with advance dementia among their “five things physicians and patients should question” lists, which were published in February on www.choosingwisely.org. For more information about AGS’ tube feeding and other Choosing Wisely recommendations, including an article in the Journal of the American Geriatrics Society, visit www.americangeriatrics.org.

References

1.     American Geriatrics Society. Feeding Tubes in Advanced Dementia Position Statement. www.americangeriatrics.org. Accessed June 7, 2013.

2.     AGS Choosing Wisely Workgroup. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc. 2013;61(4):622-631.