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"Terminal dehydration" and the analgesic effect it brings about appear to be a natural part of the dying process of many diseases."

- S.G. Post.
"Tube Feeding and Advanced Progressive Dementia".
Hastings Center Report 31, No. 1 (2001) 36-42.


Policy Concerns: Tube Feeding in Elderly Demented Patients

The US Supreme Court has affirmed an individual right to forgo or withdrawal life sustaining treatment, even including artificial nutrition and hydration. Decisions about utilizing or stopping of feeding tube should be made based on the informed preferences of a person or a surrogate within the boundaries of state law. Existing synthesis of the research literature has found that the use of feeding tubes in patients with severe dementia does not prolong survival, prevent aspiration pneumonia, or improve patient functioning (see references below). Existing research, including findings from the Brown Center for Gerontology and Health Care Research has found dramatic variation in the use of feeding tubes across the nation. The reasons for this ten fold variation in the use of feeding tubes is not clear. Potential reasons include state differences in nursing home regulatory oversight regarding citing nursing homes for weight loss and dehydration, financial incentives to provide overly technological care, and physician practices in writing DNR orders. Patient preferences as noted in the MDS with an order to forgo artificial hydration and nutrition does not explain the observed state differences in the use of feeding tubes. Ensuring that variation in feeding tube use reflect patient preferences is an important priority for policy makers.

How do Nursing Home Regulations Affect the Decision to Tube Feed?

Federal regulations require nursing homes to ensure that their residents are provided with adequate nutrition and hydration. The Federal statute governing grants to states for Medicaid programs mandates that "a nursing facility must provide…dietary services that assure that the meals meet daily nutritional and special dietary needs of each resident." This statute is implemented by regulatory provisions (see box below). Quality indicators, which the Center for Medicare and Medicaid Services will report for each Medicare certified nursing home in Fall 2002, monitor rate of weight loss. Such quality indicators while drawing an important focus on weight loss, may have the unintended consequence of resulting in more feeding tube insertions.

Since two systematic review of the literature have questions the benefits of feeding tubes, routine insertion of a feeding tube as a strategy for complying with government regulation is not the most effective way of handling the situation. Rather, nursing homes should have the adequate staffing to allow hand feeding of residents as a standard of care. Feeding tubes should not be utilized as means of achieving cost savings. Rather, the decision to utilize a feeding tube should be based on patient need, their informed preferences, and consistent with existing state law.

Both Federal and State nursing home inspection should insure that an appropriate work up of difficulty swallowing and weight loss is undertaken and that patient informed preferences are considered in the decision to insert a feeding tube.

  • Nutrition. Based on a residents' comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that his is not possible.
  • Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

How Does Current Medicare Reimbursement Polices Affect the Use of Feeding Tubes?

The financial incentives for nursing homes is to provide overly technological care, rather than medical care that takes the time and effort to ensure that patient preferences are considered in the decision to use a feeding tube. Simply stated, nursing homes are reimbursed at higher rate for the use of feeding tubes. "Skilled care" days (for which tube feeding is included) reimburses nursing homes a significantly higher amount than "Custodial care" days, which would include assisted oral. Hand feeding of nursing home residents with swallowing problems is labor intensive. Multiple studies document inadequate staffing secondary to inadequate nursing home reimbursement. Potentially, this leads to more feeding tube insertions.

What Role do Physician's Play in Guiding Family Decisions?

First, physicians must recognize that the use of feeding tubes is generally ineffective in prolonging life, preventing aspiration, and even providing adequate nourishment in severely demented patients. Physicians should guide patients and families through the decision making process of whether to use a feeding tube. Such discussions must include frank information on the risks and benefits of using feeding tubes in patients with severe dementia. Physicians must be pro-active in demanding that patient receive appropriate swallowing assessment and adequate trials of hand feeding.

Feeding Tube Resources and Position Statements:

American Dietetic Association

Alzheimers Association

American Medical Association

American Society for Parenteral and Enteral Nutrition

Gastrostomy Support



  1. Gillick, M. R. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 342(3), 206-10. 2000.

  2. Finucane, T. E., Christmas, C., and Travis, K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 282(14), 1365-70. 99.

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