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Are Feeding Tubes Futile Care or Morally Obligatory?

Posted Mar 14 2010 6:17am

Hypocrisy : The practice of professing beliefs, feelings, or virtues that one does not hold or possess; falseness.

Which of the following medical tests or procedures do physicians commonly recommend, but state they would never accept themselves?

(1) Cardiac catheterization
(2) Screening colonoscopy
(3) Feeding tube placement
(4) PSA screening for prostate cancer
(5) Hip replacement surgery

Answer appears at the post’s end.

Last week, I was asked by a primary care physician to place a feeding tube in an NNHP, a nonagenarian nursing home patient. The patient had a panoply of active medical issues, and was at the end of life. The feeding tube was advised because the patient’s swallowing function was impaired and he was, therefore, at risk for pneumonia if he ate. These swallowing evaluations are generally performed by speech pathologists, whom I have found to be dedicated and competent professionals. As an aside, they often uncover swallowing defects that suggest that eating regular food may be unsafe, even though I suspect that these ‘defects’ were present for several years. Somehow, these patients ate regular food and survived.

As the patient was not capable of providing informed consent, I contacted the patient’s legal guardian, who is his grandson and a physician. While I was hoping that he would decline the tube and opt for comfort care, he was adamant that the tube be placed. I did so on the following day. Yesterday, a day after the tube was placed, he died, not from a complication of the procedure, but because he had reached the end of his life.

In 20 years, I’ve place over a hundred feeding tubes, primarily in elderly and demented individudals. In most of these cases, I serve as a technician. I am not consulted for my advice on whether a feeding tube is in a patient’s interest, but am asked to insert one after the decision has already been made. More than any other gastro procedure I perform, placing these tubes, called PEGs by physicians, is the most troubling. There is no question that gastroenterologists like me are placing more of these tubes than are medically necessary. Over the past few years, several medical papers have documented that providing tube nutrition for patients at the end of life, or with advanced dementia, provides no benefit. It does not prolong or improve life for many of these patients. Why, then, do we do it so often?

  • We do it because primary care physicians ask us to do it.
  • We do it because families believe that withholding nutrition means they would be starving granny.
  • We do it because nursing homes don’t have the time or manpower to feed patients.
  • We do it because it has become an expected medical recommendation when patients cannot adequately feed themselves.
Because placing these tubes is often the default recommendation, physicians must actively intervene to prevent placing them. Futile care should not have to be abrogated by a physician; it should not be contemplated in the first place. We should assume instead that an individual who is swirling in the latter phases of dementia does not need a feeding tube, unless there are persuasive arguments to the contrary. We should have to justify that a PEG is needed, rather than prove that it is not necessary.

There is a theological aspect to this issue.  Traditional Jewish law mandates nutrition, even by feeding tube, in all instances, with rare and specific exceptions. While I have enormous respect for these religious laws and precepts, I cannot always reconcile them with my own feelings as a physician vis-a-vis individual patients. Judaism teaches that every moment of life has infinite value. I respect this unshakeable conviction in a world with elastic values and slippery slopes. While many advocate changing the definition of death for various reasons, Judaism stands as a bulwark against ethical erosion. Yet, I am personally torn when I am asked to place a feeding tube when I cannot appreciate the benefit that will result from this intervention.

The Catholic view on this issue is similar.  U.S Bishops recently announced feeding tube policies, which obligate feeding in nearly every individual, including those in a permanent vegetative state, with rare exceptions.  This religious directive could conflict with a patient's stated end of life wishes.

There is a double standard at play here.  I cannot count how many physicians have told me they would never have a PEG tube personally, yet they prescribe it regularly for their own patients. What oath did we all take? Was it the Hypocritic Oath?

If you've read this far, then you don't need an answer key to the multiple choice question above.
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