Gastrostomy Tube Placement in Patients With Advanced Dementia or Near End of Life

Abstract

Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.

Enteral Nutrition and Dementia Integrating Ethics

“…There are several options to consider for optimizing the communication process between the healthcare providers and the family/designated decision‐maker before the placement of a long‐term feeding tube for a patient with advanced dementia. Suggested options include (1) use of a checklist for decision‐making prior to gastrostomy tube placement as the example shown in Figure ; (2) apply principles of an informed consent process that include disclosure, comprehension, voluntary choice, and authorization; (3) palliative care consult to assist with complex decision‐making; and (4) completion of a POLST after a thorough discussion between the healthcare provider and the family/designated decision‐maker.…”

Ethical Decisions for Withholding/Withdrawing Medically Assisted Nutrition and Hydration

“…for ethical issues of feeding and hydration. [5][6][7][8][9][10][11] For millions of Americans who work in health care, including RDNs, providing high-quality care for people who are nearing the end of life is a matter of professional commitment and responsibility. A substantial body of evidence shows that broad improvements by professional societies, health care delivery organizations, and health care professionals regarding end-of-life care are within reach.…”

“…have developed practice and position papers, ethics columns, and a special report dealing with ethical decision making for medically assisted nutrition. 5,6,9,11,[18][19][20] Figure 1 depicts the process RDNs should use to apply the Academy/CDR Code of Ethics to ethical decisions for withholding/withdrawing medically assisted nutrition and hydration.…”

“…(Developed by the International Clinical Ethics Section of A.S.P.E.N.) 2014 11. Public education and engagement.…”

Feeding and hydration in terminal stage patients

“…The authors conclude that despite the very large number of patients receiving this intervention (in US, 34% of 186.835 nursing home residents with advanced cognitive impairment) there was insufficient evidence to suggest that enteral tube feeding is beneficial in these patients. Another alternative treatment, gastrostomy, has been largely discussed in a recent systematic review by Baird et al [14]. They suggest a strategy based on the results of a thorough literature review and provide tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision-making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices.…”