Introduction
I want to briefly review my disclosures. I perform legal work for litigation and own a private practice. I am receiving an honorarium from SpeechPathology.com for this course.
In this Part 1 course, we are going to look at concerns that impact the decision-making process for patients and families. These concerns include religious beliefs and culture. There are a number of advance directives that I will discuss as well as resources that will help the patient and family with the difficult choices that they may encounter in their health care.
Artificial Nutrition
Short-term
With artificial nutrition and hydration, there is usually a choice between an NG tube versus a PEG tube. In my area, NG tubes are generally placed when a patient has initial dysphagia from a stroke or when the swallow begins to have some difficulties. The placement for an NG tube is usually short-term, about a 30-day timeframe. Some doctors will let it stay in place for six to eight weeks, and I have actually seen patients who have had them in place for months. This can actually cause significant difficulties. There can be reflux because the two sphincters are open, and a stricture can actually occur from an NG tube being in for too long. NG tubes are easy to extubate and this can happen with patients. Additionally, positioning of the tube must be monitored during feeding because of the incidence of reflux.
Long-term
For more long-term options, the PEG tube is traditionally used. There is also a J tube which is the preferred method when dysphasia therapy has not made a difference in creating a safe swallow in a short amount of time.
When dysphagia occurs, especially after a stroke, typically the NG tube is placed first. Then we do try some therapy. The PEG might be placed if we haven’t worked on the swallow to make it safe. However, in many parts of the country, because patients are now transferred very quickly, many facilities will not admit a patient if they have an NG tube. As a result, many PEGs are being placed relatively early which goes against what the literature suggests is safe. Some studies state that they should not be placed up to 30 days after the initial insult because of the high mortality rate in the first 30 days.
When considering choices to alternative nutrition and hydration, patients have short-term options, long-term options or patients can say “thanks but no thanks”. Often, it comes down to quality of life for patients. Many of you have probably had patients and families who have said that eating is their loved one’s last pleasure in life. They want them to eat regardless of the consequences. It really is the patient and the family’s decision. We can make recommendations, educate and answer questions because we want this to be an informed decision for the patient and/or family. But we cannot force them into any one decision. We need to be sure we are providing them with options.
Statistics
I wanted to find some recent literature on the cost for just the feeding aspect of a PEG. The latest figures I found suggest that it costs about $32,000 a year just for the feeding. That amount does not include the nursing time to take care of the patient or the equipment that is required for the feeding.
The decision to make a patient NPO is not easy. There are many factors to consider in making that decision because we are changing the person’s quality of life. And because of that, there is often resistance from patients and their families.
With NPO status, there can be disuse atrophy and the muscles begin to spasm shut. If we don’t use those muscles we lose them. The impact of muscle disuse atrophy is found on type II muscle fibers, which are the fast twitch fibers seen in swallowing. Once disuse atrophy occurs, it can be difficult to reverse. Patients who have been NPO for months, or even years, can take a very long time to work through muscle disuse atrophy.
Disuse atrophy often occurs within the first 72 hours of being NPO, but some clients have had it happen as early as 36 hours after being NPO. It doesn’t take long for the muscles to lose their ability to work. When a feeding tube is placed, the patient doesn’t have to swallow as often as they do with oral intake. If they have dry mouth, there are no secretions to swallow. Therefore, it is very easy for the muscles to stop working.
