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Fast Fact and Concept #084: Swallow Studies, Tube Feeding and the Death Spiral, 2nd Edition

First Author: David E. Weissman, MD

The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming. It is now common practice for such patients to undergo a swallowing evaluation and if there is significant impairment to move forward with feeding tube placement (either nasogastric or gastrostomy) – see Fast Fact #128. Data suggests that in-hospital mortality for hospitalizations in which a feeding tube is places is 15-25%, and one year mortality after feeding tube placement is 60%. Predictors of early mortality include: advanced age, CNS pathology (stroke, dementia), cancer (except early stage head/neck cancer), disorientation, and low serum albumin.

The clinical scenario, the tube feeding death spiral, typically goes like this:
1. Hospital admission for complication of “brain failure” or other predictable end organ failure due to primary illnesses (e.g. urosepsis in setting of advanced dementia).
2. Inability to swallow and/or direct evidence of aspiration and/or weight loss with little oral intake.
3. Swallowing evaluation followed by a recommendation for non-oral feeding either due to aspiration or inadequate intake.
4. Feeding tube placed leading to increasing “agitation” leading to patient-removal or dislodgement of feeding tube.
5. Re-insertion of feeding tube; hand and/or chest restraints placed.
6. Aspiration pneumonia.
7. Intravenous antibiotics and pulse oximetry.
8. Repeat 4 – 6 one or more times.
9. Family conference.
10. Death.

Note: at my institution, the finding of a dying patient with a feeding tube, restraints, and pulse oximetry, is known as Weissman’s triad.

Suggestions
• Recognize that the inability to maintain nutrition through the oral route, in the setting of a chronic life-limiting illness and declining function, is usually a marker of the dying process. Discuss this with families as a means to a larger discussion of overall end of life goals.
• Ensure that your colleagues are aware of the key data and recommendations on tube feedings (see Fast Fact #10).
• Ensure there is true informed consent prior to feeding tube insertion—families must be given alternatives (e.g. hand feeding, comfort measures) along with discussion of goals and prognosis.
• Assist families by providing information and a clear recommendation for or against the use of a feeding tube. Families who decide against feeding tube placement can be expected to second guess their decision and will need continued team support.
• If a feeding tube is placed establish clear goals (e.g. improved function) and establish a timeline for re-evaluation to determine if goals are being met (typically 2-4 weeks).

References
1. Finucane TE, et al. Tube feeding in patients with advanced dementia. JAMA. 1999; 282:1365-1369.
2. Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996; 348:1421-24.
3. Cowen ME Et al. Survival estimates for patients with abnormal swallowing studies. JGIM. 1997; 12:88-94.
4. Rabeneck L, et al. Long term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. JGIM. 1996; 11:287-293.
5. Grant MD, et al. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998;279:1973-1976.
6. Mitchell SL. Clinical Crossroads: a 93-year-old man with advanced dementia and eating problems. JAMA. 2007; 298:2527-2536.
7. Cervo FA, Bryan L, Farber S. To PEG or not to PEG. A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics. 2006;61:30-35.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Weissman DE. Fast Fact and Concept #84. Swallow Studies, Tube Feeding, and the Death Spiral. 2nd Edition. October 2007. End-of-Life/Palliative Education Resource Center (www.eperc.mcw.edu).

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: January 2008

Format: Self-Study Guide Books

Purpose: Instructional Aid, Self-Study Guide, Teaching

Educational Objective: <p>Fast Fact</p>

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Gastrointestinal, Neurologic, Non-pain symptoms/disorders/syndromes

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