Artificial Enteral Nutrition & Time-limited Trials

Kyle P. Edmonds, MD

Assistant Clinical ProfessorDoris A. Howell, MD, Palliative Care ServiceUC San Diego Health System

Informed consent Series

• The problem

• What is likely

• Benefits & burdens

• Medically-appropriate options

Ethical Principles

• Withdrawing = withholding

• Autonomy allows for pt refusal of medical care

• Clinicians balance benefit & harm

Ganzini M. 2006.

Legal principles

• US case law: artificial nutrition is a medical intervention & can be refused (Cruzan)

• Specific requirements will vary state-to-state

Ganzini M. 2006.

Case86 year old woman with FAST 7D Alzheimer-type dementia is on her third admission from her board & care in six months for sepsis of

urinary origin. Her infection has improved and she is nearing discharge.

As you are leaving the room early in the morning on her final day the daughter says “oh, doc, she’s not eating very much and when she does, she coughs. Oh and she’s

been losing weight…”

AD Likely course

• Eating problems develop in 86% w advanced dementia39% die w/in 6 mos2/3 of NH residents don’t want a FT

Teno, 2011.

AD Likely course

Mitchell SL. 2009.

No dysphagia

Dysphagia

AD Last 3 Months: morbidity

•Pneumonia (37%)

•Fever (32%)

•Eating problems (90%)

Mitchell SL. 2009.

Physiology in Dying

• Constitutional Weakness Fatigue

• GI: Loss of ability to swallow Dehydration Ileus Symptoms: anorexia; nausea; dry mouth

What are pt / family goals?

• Desire to Improve strength Avoid “starvation”

• Meaning of food / eating

Patient/Family Meaning

•“Food” = ?

Patient/Family Meaning

•No! “Food” =

Patient/Family Meaning-Making

Johnson et al., 2011.

Specific Disease States

• Artificial nutrition may be a “Bridge” therapy in:

• Severe mucositis (H&N CA, BMT)

• Acute stroke with dysphagia

• Early ALS (before Resp Failure)

• Obstructions (H&N CA or GI CA)

Burden of ANH

• Breathlessness

• Edema

• Ascites

• Nausea / vomiting

• Polyuria

Outcomes…

Ganzini M. 2006.; Teno J. 2011.

• IncreasedMortality

• IncreasedTime in restraints

• IncreasedIn-hospital mortality

• IncreasedComplication rate

…Outcomes

Ganzini M. 2006.

• IncreasedAspiration PNA

• Same (worse?)

Skin integrity

• Same (worse?)

Wound healing

• Same (worse?)

Symptom control

Case

86 yoF with advanced dementia & recurrent infections now with weight loss and anorexia

Found by SLP to have aspiration with all consistencies.

Diagnosis?

Options?

Decreasing food intake•Fear: Starvation

•ManagementNormalize & ReframeFood for comfortAspiration risk

Role of the team

1. Diagnose dying

2. Use “not medically appropriate”

3. Assure comfort, non-abandonment

4. Discuss alternatives

5. Develop clear time-limited trials

6. Involve, inform other members (RN, SLP)

Potential Goals of Care

Restorative or Cure

Return to Baseline

Improve Survival

Improve Function

Relieve Symptoms

Allow Natural Death

Adapted from Mulkerin, 2011.

Decision-making Pendulum

Paternalism Autonomy

Values

Hopes

Wishes

Personhood

Lifestory

Goals of Care

Medical Options

Patient/Family Clinicians

Ventilator

Pressors

Code Status

Antibiotics

Disposition

The Plan of Care

Time-Limited Trials• A structured medical intervention

• Gather all parties

• Agree on: Exact length of time Specific goals (reasons to continue) Specific burdens (reasons to stop) What will happen if goals not met

• Reevaluation

Evidence conclusion

Destination therapy with artificial enteral nutrition is a burdensome intervention with very limited medical-appropriateness. In cases

where family is resistant to this recommendation, a structured time-limited trial would be appropriate.

Palliative Care is…

• A team that can help your patients and families manage the pain, symptoms, and stress of serious illness.

• Available at any age and at any stage in a serious illness and can be provided along with curative treatment.

• Expert communication for challenging situations.

• Partnering with you for better outcomes by helping your patients tolerate curative treatment.

References• Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced

dementia: A review of the evidence. JAMA 1999;282:1365–1370.

• Ganzini, Linda. "Artificial Nutrition and Hydration at the End of Life: Ethics and Evidence."Palliative and Supportive Care 4 (2006): 135-43. PMID: 16903584

• Koretz, Ronald L., MD. "Do Data Support Nutrition Support? Part I: Intravenous Nutrition."Journal of the American Dietetic Association 107 (2007): 988-96.  PMID: 17524720

• Koretz, Ronald L., MD. "Do Data Support Nutrition Support? Part II: Enteral Artificial Nutrition."Journal of the American Dietetic Association 107 (2007): 1374-1380.  PMID: 17659905

• Mitchell, SL et al (2009). The Clinical Course of Advanced Dementia. NEJM. 361 (16). 1529-1538.

• Teno JM et al. (2011). Decision-making and outcomes of feeding tube insertion: A five-state study. J Am Geriatr Soc. 59: 881-886.