FEEDING TUBES

    Although artificial hydration and nutrition clearly come under the category of “life support” from a medical perspective, their applications in end-of-life situations are often considered differently. This may be because the concepts of nurturing and comfort are commonly associated with nourishing the patient back to health, or because eating and drinking are fundamental needs for survival and comfort.  Feeding tubes are appropriate in patients who cannot take adequate oral intake and have reasonable possibility of recovery. Such individuals may be expected to regain alimentary function or may continue to have a desirable, quality life without alimentation (through permanent tube feeding).

    The provision of artificial hydration and nutrition through tubes, however, whether I.V., naso-gastric, or PEG (percutaneous endoscopic gastrostomy) tubes, typically provides prolongation of life but does not provide the pleasurable or comforting sensations associated with drinking and eating. Furthermore, individuals who have lost cognitive function or awareness, such as individuals with persistent vegetative state, coma or end-stage dementia, have lost the ability to experience hunger and thirst. Withholding food and drink from individuals who can swallow is almost always inappropriate, even when hand feeding is required. Withholding feeding tubes in individuals with irreversible conditions in which death is imminent or quality of life becomes unacceptable to the patient is typically appropriate. “Starvation,” which implies suffering, cannot occur in such individuals and artificial hydration and feeding serves only to prolong the dying process.  Furthermore, feeding tubes may be harmful, through prolongation of dying; and because volume loading at death increases discomfort through pulmonary congestion, increased aspiration, airway edema and congestion, increased swelling, increased urination/incontinence, and reduced endorphin levels. Specifically, with regard to advanced dementia patients, a review of 77 studies conducted over 33 years found that tube feeding offered absolutely no benefit and even caused some harm.(1)

^[1] Finucane T, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282(14):1365-1370.
 

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