Perceptions about Artificial Feeding

Perceptions about enteral tube feedings vary, but in general, surveys of elderly patients show that the majority would not want artificial feeding were they to develop advanced dementia; these opinions were common in groups educated about the procedures involved and the adverse effects, in particular the possible need for restraint. Surveys of physicians generally support not placing feeding tubes when elderly patients, or those at end of life, are no longer eating; yet in reality feeding tubes appear to be used more often than such surveys would predict. Surrogates opt for feeding tubes more often than the patients would, but these decisions rely on an incomplete knowledge base of benefits and adverse effects.

A number of variables are likely at play in the outcome of tube feeding decisions. Historically the roots of artificial feeding are deep. For centuries, it was a foregone conclusion that food must be provided when patients were not eating. Supplemental nutrition has also been intrinsic to sound surgical management for over 100 years. Another major variable, as just noted, is poor understanding of benefits and risks. This deficit seems to be most evident in families and non-physician providers. Physician surveys suggest that these providers are knowledgeable but because tubes are placed anyway, other factors are likely at work. One is found in federal regulations for nursing homes, which require adequate nutrition for residents. However, this is not the only variable. Mildred Solomon surveyed physicians who reported acting "against their conscience" (Solomon, p. 16) in providing certain life-sustaining treatment. Others have cited a fear of litigation were a tube not to be placed. Christopher Callahan has suggested that practice patterns tend to dictate PEG placement when patients stop eating. Moreover, the underlying illness may serve as a distraction by occupying center stage such that the placement of a feeding tube is relegated to a lower priority. To completely educate patients and/or families is time consuming and it is simply easier for tube placement to be the default position when the question of supplemental nutrition arises. Often this proceeds without disclosure and hence without informed consent.

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