TUBE FEED OR NOT TO TUBE FEED OR NOT TO FEED? FEED?

A Palliative Care Physician’s A Palliative Care Physician’s perspective on artificial perspective on artificial hydration and nutritionhydration and nutrition

James Hallenbeck, MDJames Hallenbeck, MD

Director, Palliative Care Director, Palliative Care ServicesServices

VA Palo Alto HCS VA Palo Alto HCS

Pre-TestPre-Test

A) Complete esophageal obstruction due A) Complete esophageal obstruction due to esophageal cancer in a patient with hunger. to esophageal cancer in a patient with hunger.

B) A patient with advanced Alzheimer’s B) A patient with advanced Alzheimer’s disease and recurrent aspiration pneumoniadisease and recurrent aspiration pneumonia

C) A patient with Parkinson’s disease, C) A patient with Parkinson’s disease, living at home, who needs to be fed and yet living at home, who needs to be fed and yet takes a very long time to feed.takes a very long time to feed.

D) A patient with stroke a week ago, who D) A patient with stroke a week ago, who cannot eat without choking. cannot eat without choking.

For which of the following For which of the following conditions would you advice PEG conditions would you advice PEG

tube placement? tube placement?

What reason would you give and What reason would you give and what evidence supports your what evidence supports your recommendation?recommendation?

What do you say when What do you say when asked…asked…

““Doctor, she’s loosing so Doctor, she’s loosing so much weight. Do you think much weight. Do you think we should put in a tube or we should put in a tube or something…”something…”

““You can’t just let her You can’t just let her

starve to death!”starve to death!”

“ “ He’s aspirating. We’ll need a PEG tube.”He’s aspirating. We’ll need a PEG tube.”

ObjectivesObjectives

Cite evidence for and against the use of Cite evidence for and against the use of tube feeding in certain situationstube feeding in certain situations

Discuss potential benefits and burdens Discuss potential benefits and burdens with a patient or family, incorporating with a patient or family, incorporating this evidencethis evidence

List possible advantages and List possible advantages and disadvantages to hydration at the end disadvantages to hydration at the end of lifeof life

By the end of this session you By the end of this session you will be able to…will be able to…

Artificial Nutrition and Artificial Nutrition and HydrationHydration

Difficult Decisions…Difficult Decisions…

Relevant FactorsRelevant Factors Effect on life expectancyEffect on life expectancy Effect on quality of lifeEffect on quality of lifeValues/Belief systems:Values/Belief systems:

Patients (may or may not be known)Patients (may or may not be known) FamilyFamily Clinical staff (physicians, nurses, speech therapists Clinical staff (physicians, nurses, speech therapists

etc.)etc.) Social/cultural belief systemsSocial/cultural belief systems

Healthcare system Healthcare system Effect on workloadEffect on workload Effect on reimbursementEffect on reimbursement Fear of recrimination Fear of recrimination

Ethical/Legal/Policy ConcernsEthical/Legal/Policy Concerns

Life Prolongation – What is Life Prolongation – What is the Evidence?the Evidence?

WeakestWeakest StrongestStrongest

Acute, Acute, catabolic catabolic illnessillness

Advanced, Advanced, terminal terminal illness – illness – Dementia, Dementia, CancerCancer

Life Enhancement – What is Life Enhancement – What is the Evidence?the Evidence?

WeakestWeakest StrongestStrongest

Patients with Patients with hunger, good hunger, good functional functional status, status, mechanical mechanical barrier to eatingbarrier to eating

Patients with Patients with no hunger, no hunger, poor base-line poor base-line functional functional status, status, terminally illterminally ill

Who gets PEG tubes?Who gets PEG tubes?

Top three categories –Top three categories – Organic, neurologic/dementia 28.6%Organic, neurologic/dementia 28.6% Stroke 18.9%Stroke 18.9% Head and neck cancer 15.7%Head and neck cancer 15.7%

Procedural complication rate 4%Procedural complication rate 4% Short-term mortality 23.5% died during Short-term mortality 23.5% died during

hospitalizationhospitalization Median survival 7.5 monthsMedian survival 7.5 months

Rabeneck, L., N. P. Wray, et al. (1996). "Long-term Rabeneck, L., N. P. Wray, et al. (1996). "Long-term outcomes of patients receiving percutaneous endoscopic outcomes of patients receiving percutaneous endoscopic

gastrostomy tubes." gastrostomy tubes." J Gen Intern MedJ Gen Intern Med 11(5): 287-93. 11(5): 287-93.

N = 7369N = 7369

Prospective Cohort Study Prospective Cohort Study on Dementiaon Dementia

Tube PlacementTube Placement 50% received a new tube50% received a new tube 31% left without a tube31% left without a tube 17% came and left with a tube17% came and left with a tube

MortalityMortality 85% discharged alive85% discharged alive Median survival: 175 daysMedian survival: 175 days No survival advantage to tube feeding No survival advantage to tube feeding

p=.90p=.90Meier, D. E., J. C. Ahronheim, et al. (2001). "High Meier, D. E., J. C. Ahronheim, et al. (2001). "High short-term mortality in hospitalized patients with short-term mortality in hospitalized patients with

advanced dementia: lack of benefit of tube advanced dementia: lack of benefit of tube feeding." feeding." Arch Intern MedArch Intern Med 161(4): 594-9. 161(4): 594-9.

N=99N=99Of 99 patients Of 99 patients hospitalized with hospitalized with advanced advanced dementia…dementia…

? Major Predictors for Tube ? Major Predictors for Tube Placement?Placement?

African American ethnicity (odds African American ethnicity (odds ratio 9.43 CI 2.1-43.2)ratio 9.43 CI 2.1-43.2)

Residence in nursing home (odds Residence in nursing home (odds ratio 4.9 CI 1.02-2.5)ratio 4.9 CI 1.02-2.5)

? Tube Placement Helpful ? Tube Placement Helpful for Preventing Aspiration for Preventing Aspiration

PneumoniaPneumonia

In predicting aspiration in next 6 In predicting aspiration in next 6 monthsmonths Sensitivity 65%Sensitivity 65% Specificity 67%Specificity 67%

No statistically significant change in No statistically significant change in aspiration rates – tubed or not tubedaspiration rates – tubed or not tubed

No statistical difference in mortalityNo statistical difference in mortalityCroghan, J., E. Burke, et al. (1994). "Pilot study Croghan, J., E. Burke, et al. (1994). "Pilot study of 12-month outcomes of nursing home patients of 12-month outcomes of nursing home patients

with aspiration on videofluroscopy." with aspiration on videofluroscopy." DysphagiaDysphagia 9 9: : 141-146.141-146.

Croghan followed 22 dementia Croghan followed 22 dementia patients who underwent patients who underwent videofluroscopyvideofluroscopy

What about Quality of Life?What about Quality of Life?Limited data…Limited data…

70% no improvement in functional 70% no improvement in functional status, nutritional status, quality of status, nutritional status, quality of lifelife

50% mortality at one year50% mortality at one year

Callahan, C. M., K. M. Haag, et al. (2000). "Outcomes of Callahan, C. M., K. M. Haag, et al. (2000). "Outcomes of percutaneous endoscopic gastrostomy among older adults in percutaneous endoscopic gastrostomy among older adults in

a community setting." a community setting." J Am Geriatr SocJ Am Geriatr Soc 48(9): 1048-54. 48(9): 1048-54.

N=150N=150Community Prospective Community Prospective Cohort StudyCohort Study

Cancer and Artificial Cancer and Artificial NutritionNutrition

Two separate issues:Two separate issues:

Mechanical blockage Mechanical blockage or inability to eator inability to eat

Cancer Cancer cachexia/anorexia cachexia/anorexia syndromesyndrome

Mechanical Mechanical Blockage/Difficulty Eating Blockage/Difficulty Eating

in Cancerin Cancer

Early disease statesEarly disease states High functional statusHigh functional status Hunger and thirst presentHunger and thirst present Temporary problem (ex. Severe Temporary problem (ex. Severe

esophagitis due to chemotherapy esophagitis due to chemotherapy and radiation and radiation

Bypassing obstruction Bypassing obstruction appears indicated appears indicated especially in…especially in…

Cancer Anorexia/Cachexia Cancer Anorexia/Cachexia SyndromeSyndrome

Mediated by tumor-associated cytokines Mediated by tumor-associated cytokines (TNF), IL-1, IL-6 and LIF)(TNF), IL-1, IL-6 and LIF)

Body shifts to catabolic stateBody shifts to catabolic state Significant physiologic differences from Significant physiologic differences from

starvationstarvation Little evidence enteral feeding (or TPN) Little evidence enteral feeding (or TPN)

effective in:effective in: Improving functional status Improving functional status Other quality of life measuresOther quality of life measures Prolonging lifeProlonging life

Ethical/Legal ConcernsEthical/Legal Concerns

Artificial feeding and hydration - Artificial feeding and hydration - medical medical interventionsinterventions that can be refused by a that can be refused by a competent patient or duly appointed and competent patient or duly appointed and informed surrogateinformed surrogate

States vary in their laws regarding tube feedingStates vary in their laws regarding tube feeding Recent California caseRecent California case In “non-terminally ill’, brain damaged, but not In “non-terminally ill’, brain damaged, but not

comatose patients clear and convincing evidence of comatose patients clear and convincing evidence of prior wishes now required.prior wishes now required.

Tube Tube insertion insertion requires informed consent!requires informed consent!

Talking with Patients and Talking with Patients and Families about possible Families about possible

Artificial Nutrition Artificial Nutrition

Key Principle of Key Principle of informed consentinformed consent::

Decision maker informed Decision maker informed about potential benefits and about potential benefits and burdens burdens and and possible possible alternativesalternatives..For something like tube-feeding, For something like tube-feeding,

are the only relevant benefits and are the only relevant benefits and burdens (risks) those related to burdens (risks) those related to

the procedure? the procedure?

So, How are Clinicians So, How are Clinicians doing in Obtaining doing in Obtaining Informed Consent?Informed Consent?

1/154 documented procedure-specific 1/154 documented procedure-specific discussion of benefits, burdens and alternatives.discussion of benefits, burdens and alternatives.

12/33 definitely or probably competent patients 12/33 definitely or probably competent patients signed consent form signed consent form Surrogate signed additional 21 (despite pt being Surrogate signed additional 21 (despite pt being

competent)competent) One year mortality: 50%One year mortality: 50%

Brett, A. S. and J. C. Rosenberg Brett, A. S. and J. C. Rosenberg (2001). "The adequacy of (2001). "The adequacy of

informed consent for placement informed consent for placement of gastrostomy tubes." of gastrostomy tubes." Arch Arch

Intern MedIntern Med 161(5): 745-8. 161(5): 745-8.

Retrospective chart Retrospective chart review of 154 tube review of 154 tube placementsplacements

Talking with FamiliesTalking with FamiliesFamilies often advocate for loved-Families often advocate for loved-ones using ones using ourour language language

What is the sub-text of a request What is the sub-text of a request for artificial nutrition – usually a for artificial nutrition – usually a desire to desire to nurturenurtureIf recommending If recommending against against artificial nutrition/hydration, artificial nutrition/hydration, be prepared to offer an be prepared to offer an alternative means of nurturing alternative means of nurturing that is appropriate for the that is appropriate for the patient’s conditionpatient’s condition

Hydration in Terminal Hydration in Terminal IllnessIllness

Arguments Arguments forfor:: Minimum standard of careMinimum standard of care ? Greater comfort with hydration? Greater comfort with hydration ? Less confusion, restlessness, neuromuscular ? Less confusion, restlessness, neuromuscular

irritabilityirritability Not clear actually prolongs life significantlyNot clear actually prolongs life significantly

Arguments Arguments againstagainst:: ? Prolong dying? Prolong dying Less discomfort due to Less discomfort due to decreaseddecreased urine output, GI urine output, GI

secretions/nausea, pulmonary secretions with secretions/nausea, pulmonary secretions with pneumoniapneumonia

Decreased fluids act as natural anesthetics for the Decreased fluids act as natural anesthetics for the CNS, natural sedation, less sufferingCNS, natural sedation, less suffering

SUMMARYSUMMARY

Decisions regarding artificial nutrition and Decisions regarding artificial nutrition and hydration are difficult for clinicians, patients hydration are difficult for clinicians, patients and familiesand families

The evidence base for tube feeding in The evidence base for tube feeding in advanced, terminal illness is weak for both advanced, terminal illness is weak for both prolongation of life and improved quality of prolongation of life and improved quality of lifelife

Decision making should incorporate patient Decision making should incorporate patient and family values as well as informed consent and family values as well as informed consent regarding potential benefits, burdens and regarding potential benefits, burdens and alternativesalternatives