Feeding tube Placement: Everything to consider before having one placed
This is a topic that I am very passionate about. For those that don’t know, I am a certified nutrition support clinician in addition to being a registered dietitian. What does this mean? It essentially means that I can call myself an expert in the field of nutrition support. In other words, I specialize in working with individuals of whom are unable to meet their nutritional needs orally and subsequently require an alternative method of receiving nutrition— whether that be via a feeding tube through the gut or IV through the blood (cool, right?). I witnessed A LOT having worked with these types of patients throughout the duration of me working in a hospital setting… the good, the bad, and the in-between.
Whether or not to have a feeding tube placed is (and should be) a difficult decision for individuals/loved ones to have to make and there are several factors that should be considered before making that final decision. Unfortunately, a significant amount of individuals are quick to make this decision before fully comprehending the requirements of having a feeding tube and the risks that come with having one placed. I am here to tell you that I first-handedly witnessed numerous individuals have a feeding tube placed, that SHOULD NOT have ever had one placed. Why? Complications that come with having a feeding tube and quality of life concerns.
Let me elaborate by giving you an example of what I commonly saw when working in the hospital setting.
Picture this. Your 91-year-old father lives in a local nursing home. You get a call in the middle of the night that your father has been hospitalized and was found to be malnourished, dehydrated, confused, and lethargic on admission. A speech therapist evaluated your father and determined that he is unable to tolerate anything orally due to severe dysphagia (secondary to his alzheimers diagnosis)—food, water, and even medications. You are then presented with the question: permanent feeding tube placement or hospice? You call a family meeting to discuss this matter and ultimately 3 out of 4 of your siblings vote to have a feeding tube placed in your father. Majority rules… so you let the physician know that you opted to move forward with feeding tube placement.
You lay awake that night wondering if you made the right decision for your father. You feel as if you didn’t fully grasp what having a feeding tube placed entailed prior to coming to your decision. All you were thinking at that time was that your father was smiling when you visited with him the day prior… he seemed like his ‘normal’ self. He was even sitting up and eating a cheeseburger during your visit. How could he have progressed this fast? Wouldn’t you have noticed if he was having swallowing difficulty when he was eating the cheeseburger? At the end of the day, you feel as if you made the right decision as you can’t even being to imagine your father dying of starvation and/or dehydration. You move forward with having his feeding tube surgically placed in the AM.
Fast forward 2 weeks and your father is re-admitted to the hospital secondary to feeding tube complications. He was found to be malnourished, dehydrated, and obtunded on admission. He was also found to have an infection around his feeding tube site. The tube was also noted to be dislodged. Upon further investigation it was determined that your fathers feeding tube was not properly cared for while at his nursing facility, resulting in him becoming severely dehydrated and malnourished. The nursing facility questions why a feeding tube was even placed in the first place given your fathers alzheimers diagnosis… claims that your father ‘pulled the tube out’ and that he expressed not wanting to have a feeding tube anymore. You then start to question if having a feeding tube placed was in-fact the right decision.
The physician presents you with the question: fix the feeding tube (that has already had a significant impact on his quality of life) or choose for him to receive hospice care so he can be comfortable. You call another family meeting. After several days of going back-and-forth with your siblings on this matter you all agree that your father should move forward with hospice care, so he can be made comfortable while he lives out the rest of his life. You don’t want him to be living out his last days in the hospital, with feeding tube complications.
Sadly, I first-handedly witnessed this happen VERY FREQUENTLY when working in the hospital setting… and it breaks my heart.
There are SO MANY things wrong with this picture.
It could have been prevented.
The issue? The family did not FULLY understand what it meant to have a feeding tube, the maintenance required to have one, the risks that come with having one, and the severity of the complications that can come with having one surgically placed (including death). They also may have not factored ‘quality of life’ concerns into the picture.
I blame the healthcare system.
I blame the medical providers (us dietitians included) for not properly educating these individuals/families in this regard.
We as healthcare providers have a responsibility to go into that patients room and FULLY explain what it means to have a feeding tube— the good, the bad, and the in-between. I can’t tell you how many times I essentially witnessed individuals go into feeding tube placement blindly, not understanding the risks. I can’t tell you how many times I witnessed individuals live out their last days in misery, due to complications from their feeding tube. This needs to end. We as a healthcare system have failed in this regard. We need to work together to make sure that individuals/families are properly educated/aware of what it means to have a feeding tube… that they’ve taken everything into consideration before having one placed.
Shown below is everything (I feel) that should be taken into consideration prior to having a feeding tube placed.
Quality of life: Quality of life should take precedent over all other factors when considering feeding tube placement. Is the individual a huge ‘foodie’ that won’t want to give up eating? Or would they prefer to receive hospice care so they are comfortable and can eat whatever they want whenever they want…? How important was eating to them? Is it something that they can live without?
Comorbidities and Prognosis: What is their prognosis? Will having a feeding tube extend their life? Does the individual live with advanced dementia? Is their dementia advanced enough that having a feeding tube placed would cause more harm than good (refusing feeds, pulling the tube out, infections, recurrent hospital admissions, etc)?
Duration of needing a feeding tube: Short-term or long-term? Whether you are the post-op patient that only has a feeding tube in place for a few days or the severe dysphagia patient that needs a permanent feeding tube, duration is another factor that should be heavily considered. Some individuals may be open-minded to having a feeding tube placed for short-term use, however, would not agree to have one placed for long-term/permanent needs (as food and the ability to eat it has a significant impact on their quality of life). To each their own!
Maintenance Care: Is the individual able to take care of self at home? Are they able to provide all of the maintenance care that is required to have a feeding tube? Or do they need assistance with care? Sadly, this is something that is overlooked at times as I have first-handedly witnessed (on several occasions) patients get re-admitted to the hospital due to feeding tube complications, as it was not properly cared for at home. It is imperative that a willing-and-able individual (if unable to care for self) be present to ensure that the proper feeding regimen is followed, water flushes are given, the tube is kept patent, and supplies are ordered/kept in-stock.
Know the pros/cons of having a feeding tube: It is extremely important to properly educate yourself on the pros/cons of feeding tube placement prior to having one placed. Shown below are some factors to consider:
Potential advantages of having a feeding tube placed: Maintain adequate nutrition and/or hydration, decreases the risk of aspiration pneumonia in individuals that are unable to safely swallow orally, weight maintenance, reduced fatigue, improved resistance to infection, improvement in overall health/wellness (if no complications arise from feeding tube placement and/or maintenance), etc.
Potential disadvantages of having a feeding tube placed: Quality of life, discomfort at site of insertion, potential obstruction or perforation if not adequately placed, infection risk, maintenance care, financial burden, etc.
To summarize, not everyone is able to safely eat or drink by mouth. Some individuals require alternative methods of receiving nutrition and hydration. This is where enteral and parenteral nutrition come into the mix. Whether being fed through the gut or fed parenterally through the blood, feeding tubes can be extremely beneficial when properly cared for… even life-sustaining for some. It is imperative that we as healthcare providers take better care of this population. It is our responsibility to make sure that these individuals (and their families) are properly prepared, educated, and aware of what it means to have a feeding tube, prior to having one placed. Quality of life, comorbidities/prognosis, duration of needing the feeding tube, and maintenance requirements are all factors that should be taken into consideration prior to having one placed. It is also imperative that a caretaker be established (if unable to care for self) prior to discharging home. It is our job as healthcare providers to make sure that all of the bases are covered in this regard.
#healthcareprovidersneedtobebetter