Scrutinizing the Ethics of Tube Feeding in Demented
Jan. 20, 2000 (Atlanta) -- One of the most agonizing decisions a person may
ever have to face is what to do with a dying loved one. When a person lapses
into dementia, for whatever reason, should a feeding tube be used when they
can't eat on their own?
The answer, of course, varies with who is asked, and from what perspective
the decision is made. A Harvard Medical School professor argues in an editorial
in today's issue of TheNew England Journal of Medicine that most
patients with advanced Alzheimer's disease and other forms of dementia should
not be offered tube feeding.
"Tube feeding in this population does not seem to prolong life,"
Muriel R. Gillick, MD, tells WebMD. "As best we can tell, [feeding] tubes
are not necessary to prevent suffering, and people who think religious doctrine
dictates tube feeding may be misinformed."
Geriatric expert Christine Cassel, MD, applauds Gillick's commentary.
"What Dr. Gillick has highlighted so beautifully in this article is that
[inability to eat] signals the end stage of the disease, and we ought to be
thinking about this as a terminal illness and treating these patients with
hospice," she tells WebMD. "The knee-jerk approach, which has been
widespread in the U.S., is that if someone stops eating, you should put a tube
in and not think of it as part of the course of the advanced disease,
particularly with dementia." Cassel, who reviewed the commentary for WebMD,
is chairman of the Henry L. Schwartz department of geriatrics at Mount Sinai
School of Medicine in New York.
Though tubes placed in the stomach, called gastrostomy tubes, are not used
in the majority of people with dementia, Gillick notes that the precise
frequency is not really known. Based on 1995 figures, 121,000 elderly patients
received gastrostomy tubes, and about 30% of these had dementia.
Irrespective of frequency, few studies have shown any benefit in providing
feeding tubes to this population. "[I]t has been remarkably difficult to
demonstrate any difference in longevity between [dementia] patients with
feeding tubes and those without feeding tubes," Gillick writes. One 1997
study found no difference in survival rates between nursing home patients with
advanced dementia who were fed by hand and those who were tube fed; other
studies have confirmed this finding. Nevertheless, these studies are
observational, and it is possible, she writes, that certain subgroups, such as
"persons with vascular dementia who have difficulty swallowing because of a
small brain-stem stroke," might benefit from tube feeding.
Annette Vitale-Salajanu has a father with vascular dementia who's in a
veterans' home in Grand Rapids, Mich. She and her sister discussed the issue
with their mother, who was a nurse, and came to the conclusion not to
resuscitate her father, but to use the tube.