Time is flying by and the number of difficult tube feeding cases I am seeing continues to grow. Since August 2010 my stomach has been in knots over Mr. C, an 88 year old patient with end-stage dementia. He was not eating and his family doctor recommended placing a PEG tube. A surgeon agreed to do the minor surgery even though the patient was severely demented and in poor physical condition. The family doctor insisted that the man should not recieve food via the PEG, only fluids and medications. To me this seemed like the ultimate poor medical decision; his intake was so poor that he would surely pass away in a few weeks from starvation. When I spoke with the family and asked them to consider feeding through the tube, his wife said "I'll do whatever the doctor wants"-which meant no food via the PEG tube, much to my dismay. So he continued to recieve a pureed diet for three meals daily, even though he was not eating.

Fast forward 6 months. Since the PEG tube was placed in August, his meal intake has been very poor for months. He has recieved enough fluid through the tube to keep him alive but receives virtually no protein, carbohydrate, fat, vitamins, or minerals. Mr. C has essentially been starving to death. Now, in addition to his mental debility (Alzheimer's Dementia) has has even more severe physical debility because of his poor nutritional status. He lost over 75 pounds. Every time I check on this resident, I am amazed that he has not passed away.

However, on a recent visit to the patient I was amazed to learn that he has begun eating again, often 50-100% of his meal trays. He remains very demented and can do almost nothing for himself. If he continues to eat, he could live on for years to come, although he will remain very debiliated and confused. To me, this case is a shocking illustration of "life at all costs". Yes, Mr. C is still alive, but he cannot speak, feed himself, walk, or recognize his wife and children. Has being given fluid only, no food, through his PEG tube saved the patient's life? Or has it caused him to die a slow, agonizing death and prolong the inevitable?

Summertime

It's summertime...life is a bit more relaxed in my household. But the pace of work life is just as frenetic as always. Patients are admitted to long-term care just as frequently as at any other time of the year. I've had several difficult tube feeding situations in the past month. One that comes to mind is my patient (Mrs. P) who had a stroke at age 80. Before the stroke she was ambulatory, living alone, and driving. She had a PEG placed in the hospital after her stroke and was sent to a rehab center. Unforunately, since her admission, her recovery has not progressed. She has been hospitalized several times and is not tolerating the tube feeding well. Medications have been ordered to help move the feeding through her digestive system. The last time I checked, she was alert but unresponsive, receiving all of her nutrition and hydration from a PEG feeding with very little quality of life. Mrs. P's family is understandably having a difficult time dealing with the suddden change in Mrs. P and her lack of progress. At this point her prognosis is very guarded.

PEG Tube Feeding-When It's Appropriate-When It's Not

It is an honor and a pleasure to see my name in print, in an article for Today's Dietitian magazine titled "PEG Tube Feeding at the End of Life-When It's Appropriate, When It's Not". The article outlines situations where PEG tube feeding is appropriate and those where it might not be indicated based on evidence-based guidelines. It is clear that some patients and/or their surrogates desire tube feeding even if a medical professional does not believe that it is in the patient's best interests. This article brings some clarity to this topic for medical practitioners. As the article states, it is the job of medical professionals to help patients undertand the risk/benefit of tube feeding and assist them in making the best decision for their loved-one. In some cases, families will make a choice that the medical professional doesn't agree with.

The topic of end-of-life nutrition care is not going to go away. In fact, I predict that over the next few years there will be a major focus on the risk/benefit/costs of all types of end-of-life medical interventions. The discourse between those who believe in life at all costs and those who believe in fewer medical interventions will most likely become louder and more contentious. Stay tuned!