This is not a pretty post. It is not a politically correct one. But it is true and my frustration and disgust is overwhelming me. It is causing me to rethink my chosen profession in nursing. A profession that has always been a source of pride and satisfaction but which now leaves me feeling I am complicit in the torture of vulnerable people.
Too many physicians are creating a comfortable living by contributing to the suffering of the oldest and most vulnerable people in our communities. Of course, many-perhaps most-physicians recommend treatments to their patients without regard to how the treatments will financially benefit them. Many-perhaps most, are primarily concerned with recommending only those treatments and procedures which are proven to likely be a benefit to the patient. Those thoughtful, and intelligent physicians are not the ones that I am referencing in this article.
I am a nurse anesthetist and part of my duties include reviewing a patient’s chart before surgery. Today is like too many days when I read a chart of someone in her 80’s who is scheduled to have a feeding tube inserted through her skin into her stomach in order to allow for liquid tube feedings. Mary is 86 years-old with advanced dementia and COPD along with other medical problems. She is scheduled to have this procedure tomorrow and undoubtedly, her family thinks it is the correct thing to do. After all, if someone you love cannot or will not eat and you see she is losing weight and getting weaker, it makes sense to insert a feeding tube so that she can receive nutrition, right?
Maybe not. Mary has severe dementia, that, together with her advanced age and other medical problems will be ending her life sooner rather than later. Using a feeding tube in an effort to improve her condition is likely futile. And what is worse, it can lead to more problems and suffering without any real promise of benefit. The American Geriatric Society has a policy statement regarding feeding tubes. These doctors who specialize in treating older patients state that the evidence now does not support the use of feeding tubes in people with advanced dementia. The reason that this practice is discouraged is because of the risks to the patient's health. Those risks far outweigh any possible benefit. (You can read the policy statement here.)
Most people would agree that the only reason to put someone with dementia through the discomfort and confusion of having a surgical procedure is with the goal of improving that person's health. Family members may hope that having tube feedings will:
- improve nutritional status and overall health
- prevent the aspiration of food or liquid into the person's lungs
- with better nutrition help with the prevention of bedsores, or help with healing existing sores
Unfortunately, none of these outcomes is likely for someone with advanced dementia. In fact, health does not improve; someone with a feeding tube is MORE likely to aspirate the liquid feedings into his lungs, and MORE likely to develop new bedsores. Additionally, nursing home residents who get a feeding tube are frequently sent to the ER with complications related to the tube; it being dislodged, clogged or with infections in the skin around the tube. These patients are also more likely to have their hands restrained to prevent them from pulling on the feeding tube. Being restrained in that way increases the risks of further confusion and mental function decline.
This procedure is frequently just another stop on the healthcare conveyor belt that we put older patients on. On the conveyor belt there is always another test to do and treatment or procedure to recommend. Too often these are done without specific consideration of the individual patient's needs.
Physicians who recommend feeding tubes and who insert them should be aware of the complications. Indeed, medical ethics require that the risks be explained in detail to anyone who is signing the consent form allowing for the procedure. Do you think anyone would sign a form allowing her loved one to have a procedure that is likely to increase the chances her loved one will suffer pneumonia from aspirating into her lungs? Or increase the risk her loved one will develop a bedsore? Or have her hands tied? Would you sign that form if you are told those risks come with likely NO benefit to your loved one? I venture to say that the family members who sign the consent forms are never told about these likely complications. And so, many older, frail and vulnerable people are subjected to a procedure that may bring them more suffering without any benefits.
It seems the only benefit of this procedure is to the physician who is paid to do it.