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Expanded Recommendations on the Use of Feeding Tubes in Patients with Advanced Dementia

July 17th, 2014

Today the American Geriatrics Society (AGS) released an updated position statement on the use of feeding tubes in patients with advanced dementia. The statement was last updated by the AGS Ethics Committee and approved by the AGS Clinical Practice & Models of Care Committee in May 2013. The publication of several sentinel studies in recent years further details the natural history of eating difficulties, as well as burdens associated with tube feeding use in persons with advanced dementia, and have been added to the guideline.

The updated statement on the use of feeding tubes is published in the Journal of the American Geriatrics Society (JAGS) and available on GeriatricsCareOnline.org, and includes an extended rationale behind the 2013 recommendations, which reinforce careful hand feeding in place of using a tube feeding. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and the development of pressure ulcers. Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feeding should be part of usual care for older adults with advanced dementia.

"People living with with advanced dementia often experience eating difficulties, in conjunction with profound loss of cognitive, verbal, and functional abilities due to the progressive neurodegenerative process," said Joseph Shega, MD, chair of the AGS Ethics Committee. "Eating difficulties are considered a natural part of the disease process, and when persistent, characterize the end stage of dementia."

Caroline Vitale, MD, vice chair of the Ethics Committee added, "Patients with advanced dementia are dependent on others for all aspects of their care, and must rely on others to make decisions about the types of care they receive. Once persistent eating difficulties arise, family caregivers are often confronted with difficult decisions that typically include whether to continue hand feeding or initiate tube feeding."

AGS RECOMMENDATIONS:

  1. Feeding tubes are not recommended for older adults with advanced dementia. Careful hand feeding should be offered; for persons with advanced dementia, hand feeding is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort.
  2. Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feeding should be part of usual care for older adults with advanced dementia.
  3. Tube feeding is a medical therapy that can be declined or accepted by a patient's surrogate decision maker in accordance with advance directives, previously stated wishes, or what it is thought the patient would want.
  4. It is the responsibility of all members of the health care team caring for residents in long-term care settings to understand any previously expressed wishes of the patient (through review of advance directives and with surrogate caregivers) regarding tube feeding and incorporate these wishes into the care plan.
  5. Hospitals, nursing homes and other care settings should promote choice, endorse shared and informed decision-making, and honor patient preferences regarding tube feeding. They should not impose obligations or exert pressure on patients or providers to institute tube feeding.

About the American Geriatrics Society

Founded in 1942, the American Geriatrics Society (AGS) is a non-profit organization of over 6,200 healthcare professionals whose shared mission is to improve the health, independence and quality of life of older people. Our vision for the future is that all older adults will have access to quality healthcare that meets their unique needs. To achieve this, the AGS focuses on: educating all healthcare professionals about the special healthcare needs of older adults; advancing aging research; enhancing clinical care for older people; raising public awareness of seniors' healthcare needs; and advocating for public policy that ensures older adults have access to high quality, appropriate, cost-effective care. The AGS is a pivotal force in shaping practices, policies and perspectives in the field of older adult health and wellness.

Modified On: July 17th, 2014