Should Late-Stage Dementia Patients Receive Feeding Tubes Near the End of Life?

Older adults with dementia often develop problems with chewing and swallowing in the final stages of the disease, which can result in aspiration pneumonia. While feeding tube insertion can be a solution to these problems in some patients, research indicates that this method does not extend life or improve the quality of life for patients with advanced dementia. In fact, the insertion of feeding tubes can cause discomfort in these patients. It has also been reported that approximately 33% of older patients need to be physically or pharmacologically restrained to prevent them from removing the tubes.

Despite all of these findings, a significant number of older adults with late-stage dementia continue to undergo feeding tube insertion near the end of life. In a new study, published in the May 2011 issue of the Journal of the American Geriatrics Society, Joan M. Teno, MD, Warren Alpert School of Medicine, Brown University, Providence, RI, and colleagues shed much-needed light on the decision-making process preceding the insertion of feeding tubes in elderly patients with advanced dementia. Teno and colleagues surveyed nearly 500 adults whose elderly relatives had died of dementia. Roughly 11% of these elderly relatives had feeding tubes surgically inserted at the end of life. The researchers asked the adults about their discussions with healthcare providers regarding feeding tube insertion, the decisions they made regarding tube insertion, and outcomes related to these decisions. In most cases, the decisions were made in an acute care hospital. Nearly 14% of those with a relative who had a feeding tube inserted reported that there was “no discussion with a healthcare provider” prior to the procedure, and another 10% said that they “felt pressured by the physician to put in a feeding tube.” More than 30% reported that they were not informed of the risks of tube insertion, and nearly 40% said that the tube “bothered” their relative. In addition, 33% of those with a feeding tube were reported to be physically or pharmacologically restrained.

Based on these findings, Teno and colleagues conclude that “there are important opportunities to improve the decision-making process” regarding feeding tube insertion in advanced dementia patients at the end of life. Although decisions regarding feeding tube insertion are often made in hospitals, many of the older adults considered for feeding tube insertion are residents of long-term care (LTC) facilities. Therefore, LTC facilities should make the most of opportunities to raise awareness among residents and their families of when feeding tube insertion is, and isn’t, likely to be beneficial. When the latter is the case, they should also raise awareness of alternative palliative care options, such as comfort feeding only,. Educating residents and their relatives about feeding tubes well before a decision is needed is preferable. Ideally, an older adult would indicate his or her wishes regarding feeding tube insertion in an advance directive. To help seniors and their family members prepare advance directives, the American Geriatrics Society’s Foundation for Health in Aging has published an easy-to-understand guide to advance directives, which is available at www.healthinaging.org.