Don't Recommend Percutaneous Feeding Tubes In Patients With ...

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Don't Recommend Percutaneous Feeding Tubes In Patients With ...

Choosing Wisely®: Tube Feeding Patients

with Advanced Dementia

Tom Finucane, MD

Johns Hopkins

Bayview Medical Center

1

•Don’t recommend percutaneous feeding tubes in

patients with advanced dementia; instead offer assisted

oral feeding


Tube Feeding

An elder with advanced dementia,

bedfast and non-communicative.

Feeding is progressively more difficult.

Coughing when fed. Two recent

pneumonias.

Eating little, losing weight.

• A new bedsore. Serum albumin 2.8 gm/dl.


Tube Feeding

Wouldn’t it make sense to place a feeding

tube



to prevent recurrent aspiration

to provide adequate food and

water


Aspiration

Definition

Prevalence

Aspiration pneumonia

Definition

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

things worse


Malnutrition

Definition

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

help

Is this patient ‘malnourished’


Malnutrition defined

1. Markers of nutritional status are abnormal

2. Evidence shows benefit from additional

nutrient intake/input.


PEG and nutritional outcomes

Survival

Pressure ulcers

Infection

• Urine, lung, skin, viral

Function

Suffering


Percutaneous feeding tubes in patients with

advanced dementia: there are no RCTs

Aspiration pneumonia

• No reason a priori to expect benefit

• No data to suggest benefit

• Harm is possible

Malnutrition

• A priori: Little reason to expect benefit.

• Almost no data to suggest benefit.

• Harm likely, esp wounds, infections.


Don’t recommend

percutaneous feeding tubes in

patients with advanced

dementia; instead, offer oral

assisted feeding.


Girth Creep

“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

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