Response to Dr. Fernandez-Viadero and Colleagues and Drs. Flaschner and Katz.

Abstract

To the Editor: We appreciate the thoughts of Fernandez-Viadero et al.1 and Flaschner and Katz2 on the recently updated and published American Geriatrics Society (AGS) Position Statement on Feeding Tube Use in Advanced Dementia. The first AGS position statement, published in 1993, was based upon preliminary scientific evidence and expert opinion. The updated statement reflects scientific advances in understanding of the natural history of advanced dementia along with a greater understanding of the outcomes associated with whether a feeding tube is placed. The preponderance of the peer-reviewed evidence demonstrates feeding tube use does not prevent aspiration or the development of aspiration pneumonia, promote wound healing, or improve survival in persons with advanced dementia. Moreover, research has shown that persons with advanced dementia and a feeding tube are more likely to develop pressure ulcers and experience burdensome care transitions (e.g., emergency department visits, hospitalizations) related to complications associated with feeding tube placement, such as dislodgement, clogging, and infection. One important component of the decision-making process, as Fernandez-Viadero et al. noted, is determination of remaining life expectancy, which is a challenge in dementia, but recent studies support the notion that several sentinel events in persons with advanced dementia can effectively guide prognostication and, when observed, support an overall poor prognosis. These clinical events include the development of persistent eating and swallowing difficulties. To that end, healthcare providers should educate patients and caregivers early on in the disease process about the natural progression of dementia, including the end of life, so that individuals with dementia and their caregivers can establish goals of care that are consistent with the individual's values and preferences. For individuals with advanced dementia facing a tube feeding decision, careful hand feeding is the standard of care based upon available empirical evidence that is the embodiment of the position statement. The Choosing Wisely campaign3 lends credence to these recommendations. The campaign, sponsored by the American Board of Internal Medicine, asks specialties to identify tests or treatments that providers and patients should question; the American Geriatrics Society, American Academy of Hospice and Palliative Medicine, and American Medical Directors Association each independently listed tube feeding in advanced dementia as a treatment that should not be recommended. Although Flaschner and Katz's feedback on reducing feeding tubes is appreciated, quality measures should promote choice and honor individuals’ preferences regarding tube feeding. Creating a measure in hopes of curtailing the use of feeding tubes would go against the autonomy of individuals to make a choice for a feeding tube based on their values and beliefs. There is an opportunity and obligation to assist individuals and their caregivers who may need to make a decision about feeding tubes using advance care planning. Quality indicators for nursing homes regarding robust advance care planning that covers several important elements, including feeding tube preferences, is recommended. The AGS intends to update the Feeding Tubes in Advanced Dementia Position Statement and is in the planning stages of what to include in the next edition. Colleagues are encouraged to submit comments and suggestions that they feel would expand the scope of the position statement to Zhenya Hurd at [email protected]. Conflict of Interest: None. Author Contributions: All authors contributed equally. Rhodes, Shega, Vitale on behalf of the Ethics Committee. Malone, Unroe on behalf of the Public Policy Committee. Blaum, Wald on behalf of the Quality and Performance Measurement Committee. Sponsor's Role: There was no sponsor for this letter.