Medical and ethical aspects of long-term enteral tube feeding

Best Practices in Caring for Seriously Ill Patients

Palliative care (PC) is the art and science of providing goal-concordant care, skillfully managing complex and refractory pain and nonpain symptoms, mitigating suffering, and augmenting quality of life for seriously ill patients throughout the course of the illness trajectory. The primary team should provide generalist PC for all seriously ill patients and know when to refer patients to specialist PC. Specialty-level PC services should be reserved for complex problems beyond the scope of primary PC. This article reviews principles and best practices to support patient-centered PC.

Neurology ethics at the end of life

Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.

When Should the Appropriateness of PEG be Questioned?

PURPOSE OF REVIEW

This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction.

RECENT FINDINGS

Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.

Jordanian intensive care nurses' perspectives on evidence-based practice in nutritional care

This study aimed to explore Jordanian nurses' perspectives on the implementation of evidence-based practice and team-working related to nutritional care in the critically ill. Poor adherence to evidence-based practice and poor collaboration may contribute to nutritional failure. Fourteen critical care nurses from three healthcare sectors in Jordan were selected purposively and interviewed using semi-structured interviews. The information obtained was subjected to a thematic analysis. Four themes emerged from the study: 'undertaking nutritional responsibilities', 'approaching evidence-based practice', 'multidisciplinary team working' and 'consequences of enteral nutrition care deficits'. Although evidence-based practice was emphasised by nurses, lack of evidence-based resources, and ineffective aspiration reduction measures were found to impede adherence to evidence-based practice. Multidisciplinary team working was introduced as means to improve practice. However, ineffective nursing involvement and poor interaction were obstacles to effective sharing.

Comparative nutritional and chemical phenome of Clostridium difficile isolates determined using phenotype microarrays

OBJECTIVES

Clostridium difficile infection (CDI) is the leading cause of infectious diarrhea in North America and Europe. The risk of CDI increases significantly in the case where antimicrobial treatment reduces the number of competing bacteria in the gut, thus leading to the increased availability of nutrients and loss of colonization resistance. The objective of this study was to determine comprehensive nutritional utilization and the chemical sensitivity profile of historic and newer C. difficile isolates and to examine the possible role of the phenotype diversity in C. difficile virulence.

METHODS

Phenotype microarrays (PMs) were used to elucidate the complete nutritional and chemical sensitivity profile of six C. difficile isolates.

RESULTS

Of the 760 nutrient sources tested, 285 compounds were utilized by at least one strain. Among the C. difficile isolates compared, R20291, a recent hypervirulent outbreak-associated strain, appears to have an expanded nutrient utilization profile when compared to all other strains.

CONCLUSIONS

The expanded nutritional utilization profile of some newer C. difficile strains could be one of the reasons for infections in patients who are not exposed to the hospital environment or not undergoing antibiotic treatment. This nutritional profile could be used to design tube feeding formulas that reduce the risk of CDI.

Ten common questions (and their answers) on medical futility

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.

Problems with use of a Foley catheter in enteral tube feeding

This article discusses the unlicensed use of a Foley catheter in home enteral tube feeding in the community. It is now clear that patients on long-term enteral feeding in the community may require replacement of their feeding tubes due to deterioration, damage or tube dislodgment. Often, these conventional feeding tubes such as percutaneous endoscopic gastrostomy and radiologically inserted gastrostomy tubes are replaced with similar tubes or with balloon gastrostomy tubes. However, the use of a Foley catheter in place of conventional feeding tubes as replacement tube has been observed in a number of patients in practice and documented in literature. The Foley catheter is significantly less expensive and easily accessible than conventional feeding tubes or balloon gastrostomy tubes. However, its use as an enteral feeding tube has implications for practice in terms of its use as unlicensed product, consent, ethics and professional responsibilities. Issues relating to body image and quality of life are also discussed.

Diagnosis and management of Alzheimer's disease: past, present and future ethical issues

There is great interest in the ethical issues associated with Alzheimer's disease (AD) and related dementias given the prevalence of AD and the evolving neuroscience landscape in matters of diagnoses and therapeutics. Much of the ethics discussion arises in the tension between the principle of not doing harm (principle of non-maleficence) in this vulnerable population and the development of effective treatments (principle of beneficence). Autonomy and capacity issues are also numerous, wide-ranging, and concern (1) day to day affairs such as driving safely and spending money wisely, (2) life-time events such as designating a legal representative in case of incapacity, making a will, (3) consenting to treatment and diagnostic procedures, (4) participating in research. The latter issue is particularly thorny and illustrates well the complexity of tackling concerns related to capacity. The impetus to protect AD patients has partly led to ethics regulation and policies making research on inapt patients more difficult because of stringent requirements for signed informed consent or for showing the value of the research to this specific patient population. New issues are arising that relate to earlier diagnosis using biomarkers and (possibly soon) the use of drugs that modify disease progression. We here summarize and discuss the different ethical issues associated with AD from a historical perspective, with emphasis on diagnostic and treatments issues.

Special considerations for endoscopists on PEG indications in older patients

Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in "bridging" and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in "incurable" conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.

Inpatient tube weaning in children with long-term feeding tube dependency: A retrospective analysis

This study investigates the outcome of an intervention program to establish oral feeding after prolonged tube feeding in children. The intervention is based on supervised reduction of enteral formula within a few days supported by a 3-week program of speech therapy, occupational therapy, psychoanalytically based eating therapy, physical therapy, psychodynamic coaching, and nutritional counseling of the infant and his or her parents. Two hundred twenty-one cases were included in this study. All patients had been severely ill or were handicapped and had been exclusively fed by tube for most of their lives. The major outcome variable was complete discontinuation of tube feeding with sufficient oral feeding after treatment, defined as the child's ability to sustain stable body weight by self-motivated oral feeding. Two hundred three patients (92%) were completely fed orally after treatment. Tube feeding was discontinued completely within 8 days in mean, and mean in-patient treatment time was 21.6 days. The current method can be used by a trained and experienced team to wean tube-dependent children from prolonged tube feeding. Tube weaning should be addressed from the beginning of tube feeding in all children who are expected to restore oral feeding after the phase of nutritional stabilization. Since successful programs are rare, we were motivated to present our results of this elaborate program in this article.

Home enteral nutrition in children: a one-year experience with 184 patients in Distrito Federal, Brazil

There is little published evidence concerning home enteral nutrition therapy in children. The present work attempts to analyze the profile of pediatric patients undergoing this therapy in the Federal District, Brazil. This is a retrospective study of data of all patients younger than 18 y old enrolled in the Home Enteral Nutrition Therapy Program of the Brazilian Public Health Department, Federal District, from January to December 2005. The study covered 184 children and adolescents. The patients’ median age at the beginning of treatment was 2.00 y ( Q1–Q3: 1.00–7.00). Pathologies leading to home enteral nutrition therapy were digestive disorders (54.9%), neuromuscular disorders (21.2%), epidermolysis bullosa congenital (7.1%), congenital malformation (5.0%), cardiac disorders (4.3%), malignancies (0.5%) and miscellaneous causes (7.0%). The prevalence of the therapy was 81.23. The oral route was used in 70.7% of cases. Enteral feeding comprised mainly industrial pediatric formulas (44.9%) and hydrolyzed-protein formulas (20%). This study supports the fact that home enteral nutrition is necessary in special pediatric conditions, favoring a precocious hospital discharge and then lowering the risk of infectious processes, and stimulating the reinsertion of children in their homes, their safe environment. The need for further studies still remain, especially ones in national basis, so as to reinforce the importance of a national regulation which would benefit all Brazilian pediatric patients in need of such therapy.

Effect of physician education and patient counseling on inpatient nonsurgical percutaneous feeding tube placement rate, indications, and outcome

BACKGROUND

The decision to place a percutaneous feeding tube (PFT) in patients who are at the end of life is multidimensional and often complicated. We assessed the effect of physician education and counseling for patients and their surrogates on inpatient nonsurgical (endoscopic and radiologic) PFT placement rates, indications, complications, and mortality.

METHODS

In a pre-paid group practice, a geriatrician initiated a program of physician education and patient/surrogate counseling on the ethical and nutritional aspects of long-term enteral feeding. We compared rates of nonsurgical PFT placement (excluding those for cancer therapy or gastric decompression), indications, complications, and short- and long-term mortality in adult inpatients before (2004) and after (2005) the program.

RESULTS

In 2004 and 2005, 115 and 60 inpatients underwent PFT placement, respectively. The annual number of hospital admissions was similar, but the rate of PFT placement declined (0.80% vs. 0.44%, P < 0.0001). The indications were cerebrovascular accident (42 [37%] versus 22 [37%]), dementia (15 [13%] versus 3 [5%]), other neurological disease (28 [24%] versus 16 [26%]), and miscellaneous disease (30 [26%] versus 19 [32%]); P > 0.05. Severe infectious complications occurred in 4 (3%) versus 0 (0%) patients, P > 0.05. Mortality (2004 versus 2005) at 30 days (23 [20%] versus 11 [18%]), 1 year (62 [54%] versus 29 [48%]) and 2 years (72 [63%] versus 31 [52%]) was similar, P > 0.05.

CONCLUSION

A pilot program of educating referring physicians and counseling patients and their surrogates reduced the rate of inpatient PFT placement by nearly 50%. Indications, severe complications and short- and long-term mortality remained unchanged.

[Bioethics and nutrition in adult patients with cancer in palliative care]

Cancer constitutes a major group of chronic diseases and is the second leading cause of death in the developed countries. Palliative care proposes to offer comprehensive support to control symptoms and improve quality of life for patients and their families. Nutrition is an important tool in palliative care, helping patients with their physical, psychological, and social issues and promoting comfort and quality of life. However, in the context of palliative care, nutritional support rarely achieves its role of fully recovering and assuring nutritional status. At this point, the nutritionist must consider the individual patient's needs, preferences, and eating habits, which are essential both for controlling symptoms and assuring satisfaction and comfort. The impossibility of conventionally applying established management and the development of a new perception of the patient often raise dilemmas for professional nutritionists.

Peritonitis secondary to the migration of a trans-hepatically-placed percutaneous endoscopic gastrostomy tube: a case report

Enteral feeding by percutaneous endoscopic gastrostomy (PEG) tube has become a commonly used method of supplying nutrition to patients with impaired neurologic function. In this case study we describe a 33-year-old brain-injured patient whose PEG insertion was complicated by inadvertent malpositioning and subsequent infection. After initially being placed through the liver, the PEG tube migrated out several weeks later, resulting in intra-abdominal feed collection, peri-hepatic abscess formation, and peritonitis. Physicians should be aware of the potential for inadvertent positioning through other viscera, and consider optimal methods of intraprocedural monitoring and post placement verification.

Percutaneous endoscopic gastrostomy feeding in nursing homes: relatives' perceptions

The aim of this study is to explore the experiences of relatives of nursing home residents receiving percutaneous endoscopic gastrostomy feeding. Qualitative methodology using semistructured interviews explores the experiences and perceptions of eight relatives. Data are analyzed using thematic analysis. Four themes are constructed from the data: dependence and resulting disempowerment, having minimal or no involvement in the decision-making process for PEG placement, betrayal, and the losses associated with the social aspects of eating. There is a need for professional education about the psychosocial implications of feeding and an increased level of support for relatives to assist them to develop coping strategies. This will require an expansion of current professional roles to include assessment of individual need, setting of appropriate goals, and the coordination of the provision of multiagency services, likely to include counseling and social support. Further research is required in this field to inform service developments.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

Palliative care/physician-assisted dying: alternative or continuing care?

End-of-life care for dying patients has become an issue of importance to physicians as well as patients. The debate centers around whether the option of physician-assisted suicide cuts off, or diminishes the value of palliative care. This ongoing attention makes the crafting of advance directives from patients detailing their end-of-life choices essential. Equally important is the appointment of a health care surrogate. The surrogate, when the patient is too ill to make decisions, should be empowered to make them in his stead. No American court has found a clinician liable for wrongful death for granting a request to refuse life support. An entirely separate issue is that of legalized physician-assisted suicide. As of this writing, only Oregon has made this legal (see Gonzales v. Oregon). It is likely that this issue will be pursued slowly through the state courts, making advance directives and surrogacy all the more crucial.

Shattering the consensus on end-of-life care: Was the Schiavo case palliative medicine's Humpty Dumpty?

In October of 2005, a two-day conference, “Controversies in End-of-Life Care: Terri Schiavo's Lessons,” was jointly sponsored by Baystate Medical Center and the Smith College School for Social Work. Both the conference and this special issue of the journal are prompted by recognition that the Schiavo case has clearly generated considerable national attention, and it consequently offers palliative medicine, social work, psychiatry, neurology, and allied disciplines a singular opportunity to reflect on our clinical practices and assumptions about the management of catastrophically ill individuals. At the core of the Schiavo case was a bitter family feud, but before it ended, it became a legal battle, a political fight, a disability rights issue, and a macabre media circus. It is heartbreaking that Congress held a midnight session about the health care of one irreparably brain-damaged woman, Terri Schiavo, while ignoring the health crisis of 40 million uninsured Americans (Friedman, 2005).

The Terri Schiavo saga: the making of a tragedy and lessons learned

The recent case of Terri Schiavo has been an important medical, legal, and ethical controversy. However, much of the public discussion of the tragedy has been based on inaccurate information regarding the facts of the case and the actual legal and ethical issues involved. This article reviews the pertinent aspects of the case and the ethical and legal questions raised and highlights the lessons we should learn from this unique story.