Choosing Wisely®: Tube Feeding Patients
with Advanced Dementia
Tom Finucane, MD
Bayview Medical Center
•Don’t recommend percutaneous feeding tubes in
patients with advanced dementia; instead offer assisted
An elder with advanced dementia,
bedfast and non-communicative.
Feeding is progressively more difficult.
Coughing when fed. Two recent
Eating little, losing weight.
• A new bedsore. Serum albumin 2.8 gm/dl.
Wouldn’t it make sense to place a feeding
to prevent recurrent aspiration
to provide adequate food and
OK, OK. You know what I mean.
• Mendelson’s syndrome
• Contaminated oral secretions
Aspiration Pneumonia and PEG
There is no reason a priori to expect that
a feeding tube will reduce the risk of
aspiration pneumonia in these patients
There are reasons to worry it might make
not “sufficient”, “adequate”, “enough”
Imagine a skinny, elderly, bedfast patient with
advanced lung cancer
• Low po. Wgt loss. Low alb. Bad prognosis
• Best evidence is nutritional support doesn’t
Is this patient ‘malnourished’
1. Markers of nutritional status are abnormal
2. Evidence shows benefit from additional
PEG and nutritional outcomes
• Urine, lung, skin, viral
Percutaneous feeding tubes in patients with
advanced dementia: there are no RCTs
• No reason a priori to expect benefit
• No data to suggest benefit
• Harm is possible
• A priori: Little reason to expect benefit.
• Almost no data to suggest benefit.
• Harm likely, esp wounds, infections.
percutaneous feeding tubes in
patients with advanced
dementia; instead, offer oral
“I felt like a tank. I felt like a large mammal. A big
beast .. I was solid, man. It’s terrible to be thin and
wispy … Fat is beautiful”
Jim Morrison 1969, Wash Post 4/3/13
“generous college dining hall plan”
Hgt, wgt, BMI
5’11” (per internet), 185, 25.8
Average wgt of 5’10” 1885 West Point cadet