Download MSWord format

1. INTRODUCTION

The GMC has defined good practice in decision making on withholding and withdrawing life-prolonging treatments [1]. This, together with updated BMA guidance [2], has ensured that clinicians in the UK have an explicit framework for making the difficult and sensitive decisions necessary to provide optimum care of patients who are both unable to maintain their own nutrition and hydration and not competent to make decisions for themselves.

The publication of these documents, which are fully referenced from both the medical and legal literature, will help to reassure patients, their family and carers, and the wider public that such decisions are made in a transparent and open manner, free from ageism and are not influenced by resource constraints in the NHS. Indeed the GMC document makes clear that individual clinicians are accountable for any deviation from the published guidance.

In light of this it is felt that there are at least two conditions common in the care of older people where some specific guidance on nutrition might be of help to BGS members, namely stroke and dementia.

2. NUTRITION AND STROKE

A significant number of stroke patients are under-nourished on admission and, as with other under-nourished hospital patients; their nutritional status tends to worsen after admission. Furthermore, under-nutrition in hospital is a strong and independent predictor of morbidity and mortality after stroke [3].

Routine administration of oral nutritional supplements to stroke patients , in acute and rehabilitation phases, has not been shown to improve overall outcome and should, therefore, be reserved for those who are under-nourished on admission or have deteriorating nutritional status [4].

Enteral feeding should be considered for patients who have dysphagia following stroke [1 ]. However, early tube feeding has been shown to reduce mortality, but increase the proportion of survivors with severe disability. Nasogastric (NG) tube feeding is safer and the recommended route for those who require enteral feeding in the first few weeks after a stroke. PEG tube feeding has been shown to be associated with increased mortality and poor outcome and should be reserved for those who cannot be fed via a NG tube, or where enteral feeding is prolonged [4].

Some patients who receive PEG tubes are in the terminal phase of their illness, calling into question the appropriateness of the intervention. The physician's role is to provide best quality information [2] on the short and long-term consequences of a trial of NG or PEG feeding [6], having investigated the options, listened to all relevant parties [2] and considered the patient’s circumstances, quality of life and prognosis [7], before deciding on the appropriateness or otherwise of either procedure.

3. NUTRITION AND DEMENTIA

Anorexia, weight loss and also dysphagia are common in patients with advanced dementia. In these patients intercurrent infection, environmental change, depression, poor carer rapport, pain, oral hygiene, ill-fitting dentures and nursing availability are just some potentially reversible and treatable causes of reduced food and fluid intake. The role of enteral, mainly PEG tube, feeding in such individuals is controversial [14, 15], even in the ethical and theological literature [11].

The best available evidence, in the absence of randomised controlled trials, suggests that PEG tube feeding does not improve overall prognosis in patients with advanced dementia [9]. It does not prevent aspiration [8], prolong survival, improve quality of life, functional status or nutritional status [9,12]. The latter is likely to be due to the presence of cachexia - inducing cytokines such as TNF- and IL-612 [13]. PEG tubes are poorly tolerated by patients with dementia and there is some evidence that hand feeding can be as effective [5].

Despite the above evidence which questions the value of enteral tube feeding in general in dementia there remains a need for physicians to consider each clinical situation on its merits [6]. Each individual has a right to be treated with dignity and this can be used as an argument both for and against the administration of artificial nutrition and hydration. Respect for individual autonomy is paramount, as is extensive consultation, when acting in the best interest of a patient who is not competent. There is an acknowledged need for palliative care provision for patients with advanced dementia [10].

Where dietary intake is insufficient but death is not imminent, the GMC states that a second opinion must be sought from a senior clinician not directly involved in the patient's care, before the decision to withhold artificial feeding is finalised and that where significant conflicts remain, either within the healthcare team or with those close to the patient, legal advice should be sought [1].

4. RECOMMENDATIONS

Advice of dieticians and speech and language therapists must be sought early to assess the most appropriate method of meeting individual nutritional requirements in patients at risk of under-nutrition.

Nursing, medical, catering staff and other health professionals involved in the care of patients with stroke or dementia should have access to the necessary basic training which will enable them to assess and meet the nutritional demands of those at risk.

All members of the multidisciplinary team should be involved in decisions to recommend PEG feeding for patients with dysphagia. The treating doctor has a duty to obtain informed consent from competent patients and to undertake adequate consultation with those closest to patients not competent to make the decision.

There should be clear policies for short- and long-term review of patients with PEG feeding.

5. REFERENCES

1. Withholding and withdrawing life-prolonging treatments: good practice in decision making. General Medical Council, London, 2002
2. Withholding and withdrawing life-prolonging medical treatment: guidance for decision making. BMA London, 2nd edition, 2001
3. Gariballa, S (2000). Nutritional factors in stroke. B J Nutr 84, 5-17
4. FOOD Trial Collaboration ( 2005 ) Effect of timing and method of enteral tube feeding for dysphagic stroke patients ( FOOD ) : a multi-centred randomised controlled trial. Lancet 365 , 764 – 772.
5. Mitchell S. ,Buchanan J. ,Littlehale S. , Hamel M. ( 2004 ) Tube-feeding versus hand-feeding nursing home residents with advanced dementia : a cost comparison.. JAMDA 5(2) S23 – 29.
6. Lennard-Jones J. (1999) Giving or withholding fluid and nutrients: ethical and legal aspects. J R Coll Physicians Lond 33, 39-45
7. Rabeneck L, McCullough L, Wray N (1997) Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 349, 496-98
8. Finucane T. Bynum J. (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 348, 1421-1424
9. Finucane T., Christmas C , Travis K ( 1999 ) Tube feeding inpatients with advanced dementia : a review of the evidence. JAMA 282 , 1365 - 70
10. Hughes J. , Robinson L. ,Volicer L. ( 2005 ) Specialist palliative care in dementia. BMJ 330 57 –8.
11. Gillick M. (2000) Rethinking the role of tube feeding in patients with advanced dementia. N Eng J Med 342, 206-210
12. Mitchell S., Berkowitz R., Lawson F., Lipsitz L.(2000) A cross-national survey of tube-feeding decisions in cognitively impaired older persons. J Am Geriatr Soc 48, 391-397
13. Yeh S-S, Schuster M. (1999) Geriatric cachexia: the role of cytokines. Am J Clin Nutr 70, 183-197
14. Sanders D. , Anderson A. , Bardhan K. ( 2004 ) Percutaneous endoscopic gastrostomy : an effective strategy for gastrostomy feeding in patients with dementia .Clinical Medicine 4 ( 3 ) 235 – 41
15. Pennington C. ( 2002 ) To PEG or not to PEG. Clinical Medicine 2 (3) 250 – 55
16. SIGN 78 ( 2004 ) Management of patients with stroke : identification and management of dysphagia.