Is Tube Feeding Futile in Advanced Dementia?

Abstract

It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

“…In the last two decades, many published studies have expressed different views on whether or not the insertion of feeding tubes in individuals with advanced dementia provides more harms than benefits or vice-versa [25,27,40,[81][82][83][84][85][86][87][88][89]. Obviously, this issue continues to generate widespread debate among experts in the care of the elderly medicine [25,26,28].…”

“…While it is true that tube feeding does not provide cure for the underlying swallowing difficulty in late-stage dementia, family caregivers and healthcare providers (that support tube feeding idea) maintain that PEG feeding helps to mitigate weight loss, sustain nutrition, and reduce the suffering that occurs from dehydration or malnutrition [28,74,107].…”

“…e lack of randomised controlled trials on this topic due to ethical reasons makes the existing scientific evidence to be inconclusive. Hence, the current guidelines based mostly upon experts' recommendations and the existing observational studies whose study design and overall quality have been questioned need to be interpreted with caution [28,30]. ese guidelines have been criticised as overestimating the futility of tube feeding and understating its benefits [25][26][27][28][29].…”

“…While it may be clinically evident in certain individuals with advanced dementia that inserting the feeding tube will be burdensome and futile due to poor clinical conditions and frailty, it may, however, be beneficial for comfort and nutritional maintenance in other appropriately selected individuals who may not be clinically compromised, in order to help achieve the care plan goals [28]. e decision for PEG placement in late-stage dementia should be made on a caseby-case basis, after considering the evidence supporting potential benefits versus the substantial burden that tube feeding may constitute for the individual.…”

“…While several professional societies and experts have recommended careful hand feeding as the standard/ceiling of care for all individuals with advanced dementia who experience difficulty with oral intake [5,[22][23][24], other experts have argued in support of feeding tube placement [25][26][27][28][29]. Quite justifiably, the debate continues as there has not been any randomised controlled trial done to compare the benefits and burdens of tube feeding interventions with oral feeding in people with advanced dementia due to ethical concerns.…”