My Personal Experience With Patients Placed On Enteral Tubal Feeds
So you’re being told your loved one needs a tube feed.
During my time as a dietetic intern, I encountered a patient in a long-term care setting that had developed a significant swallowing issue termed dysphagia. The patient could no longer swallow food or drink liquids (thickened or thin) without winding up in coughing fits. This happens because the epiglottis, which separates the trachea from the esophagus, generally is no longer functioning correctly. Food and liquid were entering the patient’s airway. The patient developed aversions to food due to fear of choking. When I and the lead dietitian spoke with the patient’s family about a tube feed, they were very much against it. When probing the reason as to why one family member admitted that they had a parent that was placed on a tube feed shortly before he died — they were afraid that if their remaining parent was placed on a tube feed they were fated to repeat the experience.
You can’t fault the family member for their feelings, they are genuine. They had a bad experience, but while this family member wrestles with their concerns, the patient was still refusing food that they could not eat. Another week passed and the patient’s weight continued to decline. We again spoke with the patient’s family member about starting a tube feed. We covered the reasons why it was necessary, what the patient’s risk was starting the tube feed vs continuing to lose weight, and we covered the guidelines for starting tube feeds. We together with the patient came up with a plan that helped alleviate some of their concerns which allowed for pleasure feeding — the patient could be provided regular meals alongside the tube feed. When confronting this type of situation there are times when one needs to be both compassionate and forthright, taking into consideration not only the patient but the caretaker’s mindset and formulating a strategy that will meet both concerns.
How Does The Doctor And The Dietitian Make The Decision To Place A Patient On A Gastric Tube Feed Or Other Methods?
When a doctor prescribes a tube feed and the dietitian receives the order, we have to follow important set guidelines by ASPEN/ESPEN (American/European Society for Parenteral and Enteral Nutrition). These guidelines were developed to help ensure that patients receive adequate nutrition support in the critical care and long-term care setting to maintain optimal nutrition when patients are unable to eat food regularly. These guidelines in short summarize where we need to place the tube feed (for example, if the patient has a blockage due to oropharyngeal cancers, like a tumor blocking access to the stomach from the esophagus). Second, we determine whether enteral support (tube feeding) will be a short-term or long-term intervention — a doctor will consult the RD for suspected malnutrition, and the RD will conduct a full nutrition assessment for each patient. Then we determine which formula would be appropriate for this patient. This can depend on the patient’s own tolerances and allergies, and where the tube feed is placed. In the case of a PEG-J or PEJ tubal feed, where the patient’s food is routed directly to the small intestine, a partially hydrolyzed (where the proteins are partially broken down) formula would be more tolerable for the patient versus a complete formula.
TPN(total parenteral nutrition), or nutrition via IV, is considered when there is no level of enteral support that can help the patient — one patient I saw had a significant portion of their small intestine removed, which is where 95% of nutrients are absorbed and the remaining surface area too small to absorb.
The Goals Of Enteral Feeding And Why Families Need To Understand How It Affects The Patient
For the most part, the goal of enteral and TPN support is to help the patient get nutrients during critical illness to maintain body weight and general health. It’s a process that has been devised to help ensure the patient is adequately fed during critical illness. Malnutrition from dysphagia can rapidly become a critical illness. This is why it is of great importance for family members to understand that their medical team is keeping their loved ones’ informed about the importance of their family member’s medical needs including their prescribed nutrition plan. This way making the choice to place their loved one on tubal feeding leaves them feeling secure about either an improved prognosis or providing them with a measure of comfort for those patients that are terminally ill.