The medical literature concerning patients with advanced dementia has consistently shown that feeding tubes provide little benefit. Complications of feeding tubes can include aspiration pneumonia, diarrhea, agitation, need for physical and chemical restraint, and insertion complications such as wound infection. A new article has shown that feeding tubes can increase risk for pressure ulcers, and do not promote healing of pre-existing ulcers. This article will fuel discussion not only of risks and benefits of tube feeding, but the avoidability or unavoidability of pressure ulcers. However there were issues not addressed by this paper, such as the adequacy of nutritional content once the tube is inserted.

Jeffrey Levine MD geriatrician physician artist photographerThe paper was entitled Feeding Tubes and the Prevention or Healing of Pressure Ulcers and it was published in the Archives of Internal Medicine. The authors studied whether feeding tubes inserted directly into the stomach (PEG tubes, acronym for percutaneous endoscopic gastrostomy) are associated with pressure ulcer development and/or healing in nursing home residents. Using a very robust data set, they found that feeding tubes were not associated with prevention or improved healing, and that PEGs were associated with increased risk for pressure ulcers.

Pressure ulcers are costly, often preventable, and can result in infections, painful surgical procedures, prolonged rehabilitation, disfigurement, and death. The controversy over the avoidability of pressure ulcers has escalated over the last several years, particularly since the 2008 Medicare rule which placed hospital acquired pressure ulcers on the “no pay” list. The National Pressure Ulcer Advisory Panel jumped into the fray by issuing a consensus statement saying that not all pressure ulcers are avoidable. New theories have been developed accounting for the unavoidability of some pressure ulcers, particularly the expert consensus statement called SCALE, or Skin Changes at Life’s End.

One important variable that was not studied in the feeding tube paper was the adequacy of tube feeding content. Tube feeding delivers nutrients that include protein, calories, and vitamins, and if feeding is inadequate a state of malnutrition will ensue, and pre-existing nutritional deficits will worsen. The research evidence to support nutrition as a factor in pressure ulcer prevention has been inconclusive, but that does not mean that this relationship does not exist. Indeed most experts and clinicians, including myself, will say that malnutrition is an important factor in pressure ulcer occurrence, and nutritional support is critical for wound healing. The commonly accepted caloric requirement for wound healing is 30-35 Kcal/Kg – a factor not considered in the Archives paper.

It makes sense that tube feeding increases the risk for pressure ulceration. Patients with tube feedings must be positioned with the head of the bed elevated to lower the risk for aspiration pneumonia – but this increases shear forces and decreases the ability to turn, thereby increasing risk of developing pressure ulcers over the buttocks or sacrum. Once a tube is inserted however, the patient must receive adequate protein and calories as determined by a competent nutritionist and ordered by a physician who understands the issues. In all cases of end of life decision making, the risks and benefits of tube feedings must be thoroughly explored, and patients and their families need to make informed decisions. The growing body of research shows that tube feeding in persons in advanced dementia offers very limited benefits.

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Reference for this article is:  Teno JM et al.  Feeding Tubes and the Prevention or Healing of Pressure Ulcers, Arch Intern Med. 2012;172(9):697-701.

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