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March 2009

"Family members need to be informed, with great compassion, sensitivity, and patience, about the dying process and how natural and inevitable it truly is."

What if the doctor suggests a feeding tube? If a patient can’t or won’t eat or drink, even when spoon fed, the doctor might suggest a feeding tube. While recovering from an illness, a feeding tube can be helpful. But at the end of life, a feeding tube might cause more discomfort than not eating. As death approaches, loss of appetite is common. Body systems start shutting down, and fluids and food are not needed as before. Some experts believe that at this point few nutrients are absorbed from any type of nutrition, including that received through a feeding tube.

If tube feeding is going to be tried, there are two methods that can be used. In the first, a feeding tube, known as a nasogastric or NG tube, is threaded through the nose down to the stomach to give nutrition for a short time. Sometimes the tube is uncomfortable. If so, the doctor might try a smaller, child-sized tube. Someone with an NG tube might try to remove it. This usually means the person has to be restrained, which could mean binding his or her hands to the bed. If tube feeding is required for an extended time, then a gastric or G tube is put directly into the stomach through an opening made in the side or abdomen. This second method is also called a PEG tube for percutaneous endoscopic gastrostomy tube. These carry risks of infection, pneumonia, and nausea.

Some people try tube feeding for a short time to see if it makes a difference, while keeping open the option of removing the tube if there is no improvement. Talk to the doctor about how the feeding tube could help and how long it makes sense to try it.

Refusing food might be a conscious decision—a part of the dying person’s understanding that death is near. The decision-maker should think carefully about doing something that might be against the dying person’s wishes.

Family members should be warned about the potential medical problems associated with artificial feeding and hydration. These include, in the case of nasograstric tubes, pain and discomfort related to the forceful introduction of physical devices in the esophagus, needed sedation, and infections often resulting from the procedure.

"Many family members are not aware that no longer eating and drinking is part of the dying process, and it is normal," says Dr. Post. "Our modern culture tends to treat dying as unnatural. Our technology allows us to forestall death, yet cannot prevent it. Family members need to be informed, with great compassion, sensitivity, and patience, about the dying process and how natural and inevitable it truly is. The body is shutting down. The natural process of dying means that the body no longer wants or needs food or fluids. This is often viewed as unnatural by caregivers, and even some healthcare professionals. However, we need to explore our own feelings and attitudes toward death and dying before we can help families through this transitional process, this time of loss and change," comments Darby Morhardt, MSW, Social Worker, Northwestern University Alzheimer's Disease Center.

Cessation of food intake results in the release of endorphins, which reduce pain. Feeding tubes and hydration block the release of endorphins and can result in weeks of "unnecessary suffering" Dr. Post said, with patients "uremic and bloated and unable to clear mucus from their lungs." Percutaneous endoscopic gastronomy (PEG) feeding can result in back-up to the esophagus, increasing the risk of aspiration pneumonia, while lack of ambulation-PEG feeding often requires physical restraint to prevent patients from pulling out their feeding tubes-increases the risk for bed ulcers and skin infections.

Artificial feeding also deprives a patient of taste, says Dr. Ladislav Volicer, clinical director of the Geriatric Research, Education and Clinical Center (GRECC) at the E.N.R.M. Veterans Hospital in Bedford, Massachusetts. "Alzheimer's patients love sweets," Dr. Volicer says, "even in the later stages-things like milk shakes and ice cream." Artificial feeding also deprives patients and caregivers of personal contact, which is a meaningful activity. "We haven't had any tube feeding in the last 10 years," says Dr. Volicer, who often converts patients back to assisted feeding on arrival. "They can always eat to some degree," he says, "except during the actual dying process." Patients in the dying phase do not experience hunger and thirst, he adds.

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Source: National Institute on Aging, U.S. National Institutes of Health
Reviewed by Dr. Boaz Ancselovic, MD, Geriatrician, Alzheimer's Weekly
Edited By Peter Berger, Alzheimer's Weekly

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