Title: Fast Fact and Concept #84: Swallow Studies, Tube Feeding and the Death Spiral
Author(s): Weissman David E
The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming. It is now common practice for such patients to undergo a swallowing evaluation and if the patient "fails", to move forward with feeding tube placement (NG, JG). Data suggests that placement of feeding tubes has an in-hospital mortality of 15-25%, and one year mortality of 60%. Not surprisingly, predictors of early mortality include: high age, CNS pathology (CVA, dementia), cancer-except early stage Head/Neck cancer, disorientation, and low albumin.
The clinical scenario, the tube feeding death spiral, typically goes like this:
1. Hospital admission for complication of "brain failure" or other predictable end organ failure due to primary illnesses (e.g. Urosepsis in setting of advanced dementia)
2. Inability to swallow and/or direct evidence of aspiration and/or weight loss with little po intake
3. Swallowing evaluation followed by a recommendation for non-oral feeding either due to aspiration or inadequate intake
4. Feeding tube placed leading to increasing "agitation" leading to patient-removal or dislodgement of feeding tube
5. Re-insertion of feeding tube; hand and/or chest restraints placed
6. Aspiration pneumonia
7. Intravenous antibiotics and pulse oximetry
8. Repeat 4. - 6. one or more times
9. Family conference
Note: at my institution, the finding of a dying patient with a feeding tube, restraints and pulse oximetry, is known as Weissman's triad.
Finucane TE, et al. 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.
Cowen ME Et al. Survival estimates for patients with abnormal swallowing studies. JGIM 1997; 12:88-94.
Rabeneck L, et al. Long term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. JGIM 1996; 11:287-293.
Grant MD, et al. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998;279:1973-1976.
Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #85 . Swallow studies, tube feeding and the death spiral. Weissman, DE; February 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.
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Creation Date: 2/2003
Purpose: Instructional Aid, Self-Study Guide, Teaching
|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|
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Keyword(s): Advance directives, Antibiotics, Assisted suicide/euthanasia, Autopsy/organ donation, Blood products, Clinical interventions, Cross-cultural care, Decision making capacity/surrogates, Do not rescucitate orders, Ethics, Hydration, Informed consent, Interventional procedures, Non-oral feeding, Radiation or chemotherapy, Rehabilitation, Surgery, Treatment withdrawal, Treatment withholding
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