Fast Fact and Concept #10: Tube Feed or Not Tube Feed?

Title: Fast Fact and Concept #10: Tube Feed or Not Tube Feed?

Author(s): Hallenbeck, J.; Weissman, D.

This Fast Fact reviews data concerning the effectiveness of non-oral feeding in chronically ill and dying patients. Can be used during ward rounds or as a handout for a teaching conference.

Educational Objective(s)
Review effectiveness data of non-oral feeding in dying and seriously ill patients

Tube feeding is frequently used in chronically ill and dying patients. The evidence base for much of this use is weak, at best. In the bullets below are summarized some of what is known (and not known) about tube feeding for specific indications.

Tube feeding as a means to prevent aspiration pneumonia . . .

No study has demonstrated a reduction in the incidence of pneumonia through tube feeding.
No randomized control studies have been published. Three retrospective cohort studies comparing patients with and without tube feeding demonstrated no advantage to tube feeding for this purpose.
Swallowing studies, such as videofluoroscopy, lack both sensitivity and specificity in predicting who will develop aspiration pneumonia. Croghan's (1994) study of 22 patients undergoing videofluoroscopy demonstrated a sensitivity of 65% and specificity of 67% in predicting who would develop aspiration pneumonia within one year. In this study, no reduction in the incidence of pneumonia was demonstrated in those tube fed.
Swallowing studies may be helpful in providing guidance regarding swallowing techniques for populations amenable to instruction.
Numerous observational studies have been published, demonstrating a high incidence of aspiration pneumonia in those who have been tube fed.

Tube feeding to prolong life via caloric support . . .

Data is strongest for patients with reversible illness in a catabolic state (such as acute sepsis).
Data is weakest in advanced cancer. No improvement in survival has been found (few exceptions noted below).
Non-randomized, retrospective studies have found no survival advantage in patients with dementia.
Tube feeding may be life-prolonging in select circumstances:
1. Patients with proximal GI obstruction and a high functional status
2. Patients receiving chemotherapy/XRT involving the proximal GI tract
3. Certain patients with AIDS and wasting syndromes

Tube feeding to enhance quality of life/reduce suffering . . .

Where true hunger and thirst exist, quality of life may be enhanced (such as in very proximal GI obstruction).
Most actively dying patients do NOT experience hunger or thirst (although dry mouth is a common problem).
Dry mouth is NOT improved by tube feeding (or IV hydration).
A recent literature review using palliative care and enteral nutrition as search terms found no studies demonstrating improved quality of life through tube feeding. (Limited to a few observational studies.)
Tube feeding may adversely affect quality of life through increased need for physical restraints, infections, pain, indignity cost and the denial of the pleasure of eating.

Summary
Tube feeding should always be considered relative to patient goals. Physicians should be prepared to discuss tube feeding as an option bearing in mind what evidence (or lack thereof) exists that tube feeding will help reach such goals.

Also See:
Fast Fact #84: Swallow Studies, Tube Feeding and the Death Spiral

References: Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. JAMA. 1999; 282:1365-1369., Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996; 348:1421-24., Ahronheim JC. Nutrition and hydration in the terminal patient. Clinics in Geriatrics. 1996; 12(2): 379-391., Croghan JE, Burke EM, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy. Dysphagia. 1994; 9(3):141-146.

Fast Facts and Concepts are developed and distributed as part of the National Internal Medicine Residency End-of-Life Education project, funded by the Robert Wood Johnson Foundation.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #10: Tube Feed or Not Tube Feed? June, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 4/2000

Format: Handouts

Purpose: Teaching

Audience(s)

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice

Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Tube Feeding, Adult, Gastrointestinal, Non-oral feeding, Treatment withdrawal, Treatment withholding

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).