cover story
that it may not be possible to main- The Mental Capacity Act (2005) and enable them to understand the con-
tain nutritional status for a person with tube feeding sequences of the decision.
late stage dementia (4) and tube If tube feeding is being considered The decision to tube feed someone
feeding is no more likely to achieve for a person with dementia, the dieti- who lacks capacity can not be legally
this than continued oral intake. tian involved in their care needs to be made by the person’s family, nor can
A Cochrane Systematic Review: satisfied that the person’s mental ca- any family member who does not
Enteral tube feeding for older people pacity has been assessed (10). If the hold an appropriate lasting power of
with advanced dementia (7), found person is deemed to lack capacity, attorney, give consent for this.
‘no conclusive evidence that enteral the doctor in charge of their care will Ultimately, it is important to ap-
tube nutrition is effective in terms of ultimately make a Best Interests Deci- preciate that refusing to eat may be
prolonging survival, improving quality sion about tube feeding. This should the person’s way of expressing that
of life, or leading to better nourish- be in full consultation with all other enough is enough.
ment or decreasing the risk of pres- interested parties including relevant
sure sores. It may actually End of life
increase the risk of devel- At end of life many
oping pneumonia due to people with late stage
inhaling small quantities
Factors which can affect appetite and ability to eat
dementia show no inter-
of the feed and even
Inappropriate Lack of cooking
food provision skills
est in food or drinks. This
death.’ Respiratory tract Lack of cooking can be distressing to
Lack of appropriate
Current evidence
disorders facilities
assistance family and carers who
points to careful hand
Gut problems Lack of
Inability Poor dentition
time feel that the person
feeding being the feed-
to access
Increased nutrient must be suffering due
food
ing method of choice for
requirements
Infection
Dementia to their negligible oral
people with advanced
Wound healing
intake. However, there is
Medication
dementia, not least be-
Pain
Diabetes
side effects growing evidence that
cause it ensures continu-
Discomfort
Effects of
people at the end of life
treatment
Cancer
ation of human contact don’t suffer from more
and social interaction,
Drowsiness Mobility
than transient hunger
but it can provide both
Confusion Activity
Pressure sores
Concentration Wandering
and thirst, and they can
stimulation and comfort
Forgetfulness Dexterity
Stroke
experience comfort from
too, and therefore can
Anger Co-ordination
minimal intake of food
help to provide and
Fear Posture
and fluid (11). Experience
Depression Tremor
maintain some quality
Frustration Falls
Arthritis
in palliative care settings
of life for the person with
Dehydration
Embarassment suggests that most im-
advanced dementia (8).
Reduced
minently dying patients
To date there have
appetite
Nausea
die comfortably without
Inability to
been no randomised
communicate
Dysphagia
Diarrhoea
Parkinson’s
artificial hydration (12).
verbally or Taste changes
Constipation disease
controlled trials directly non-verbally
Reduced taste
Incontinence
comparing tube feed-
Osteoporosis
acuity
References
ing and hand feeding,
Sore/dry mouth
1 The Office of Health Econom-
Reflux
but evidence suggests
Mental illness
ics Website (www.oheschools.org/
including
ohech6pg3.html)
that nutritionally, hand
depression Age 2 Gillick, Rethinking the role of tube
Isolation Sensory Breathlessness
fed patients do at least
impairment
feeding in patients with advanced
Dependency
dementia New England Journal of
as well as those who are
Loneliness
Medicine 2000 Vol 342 No 3
Self neglect
tube fed (9).
Deprivation Progressive neurological
3 McNamara & Kennedy, Tube
disorder feeding patients with advanced
When considering
e.g. MS, MND Bereavement
Poor eating environment
dementia: an ethical dilemma
whether tube feeding
Proceedings of the Nutrition Society
© Older People’s Specialist Team September 2008
2001 60, pp 179-185
is appropriate it is im- 4 White, Nutrition in advanced
portant to consider the
Alzheimer’s disease, NC Med J 2005
Vol 66 No 4 pp 307-312
following:
5 Malone, Mealtimes and Dementia, University of
• What are you expecting to health and social care professionals,
Stirling 1996 pp 6
6 Clarke, Improving nutrition in dementia through
achieve and are these expecta- carers and family, and the role taken
menu picture cards and cooking activities, Nursing
tions realistic? by the dietitian in the decision making
Times 2009 105 30
• Has adequate information been process should be documented (10).
7 Sampson, Candy & Jones, Enteral tube feeding for
older people with advanced dementia, The Cochrane
shared with relatives and carers to Most importantly during this pro-
Library 2009 Issue 4
ensure that they do not have un- cess, all health professionals involved
8 Dennehy, Analysis of patient’s rights: dementia and
PEG insertion, British Journal of Nursing 2006 Vol 15 No
realistic expectations of what tube need to give consistent messages to 1 pp 18-20
feeding can achieve? family and carers to avoid confusion
9 Cervo, Bryan & Farber, To PEG or not to PEG: A
review of evidence for placing feeding tubes in ad-
• What would the person with de- about the plan of care. It is extremely vanced dementia and the decision-making process,
mentia have wanted? important to give relatives informa-
Geriatrics 2006 Vol 61 No 6 pp 30-35
10 Lyons, Brotherton, Stanley, Carrahart & Manthorpe,
• Is tube feeding really in the person tion regarding what is currently known
The Mental Capacity Act 2005: implications for dietetic
with dementia’s best interests? about outcomes for patients with
practice, J Hum Nutr Diet 2007 20 pp 302-310
• Will the benefits of human contact
11 Gillick, Rethinking the role of tube feeding in pa-
advanced dementia who have PEGs
tients with advanced dementia, New England Journal
and stimulation from food (during placed, and to ensure that informa-
of Medicine 2000 Vol 342 No 3
all meals, snacks and drinks) be tion given to family and carers is
12 Partridge & Campbell, Artificial Nutrition and Hydra-
tion - Guidance in End of Life Care for Adults, National
lost? adequate and in the right context to Council for Palliative Care May 2007
12 NHDmag.com Mar '10 - issue 52
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