This text-based course is a transcript of the event, “Decision-Making for Alternate Nutrition and Hydration,” presented by Denise Dougherty, M.A., CCC-SLP.
>> Denise Dougherty: This is part one of a two-part course, “Decision-Making for Alternate Nutrition and Hydration.” Today we are going to come at it from the patient and the family perspective. We often end up butting heads because we are looking at it from different perspectives – ours vs. the family's and patient’s. We are really looking more and more at quality of life.
I have a lot of patients, more than ever before, that say “Food is Mom's last pleasure in life and I want her to eat.” It really does not matter what we say as far as good outcomes or bad outcomes; they are interested in doing what they believe is most appropriate. They also come at it from a religious and cultural belief aspect. What we need to understand is everyone who comes to the decision-making table brings their culture, their religious convictions, their value and belief system, and we sometimes disagree on how we should handle this. We are also going to take a look at some advance directives that you may see in your patient's chart, and we will talk about some resources that you can offer for your patients and your families when they are dealing with this difficult decision.
Today we are going to talk about culture, religion, the advance directives, and the available resources. There is a lot you can get for free and there are some that will just cost you minimal dollars. It would be a nice thing to have in your library when you are having these discussions with patients and families.
Artificial Nutrition
NG Tube
When we take a look at the options we have to offer, certainly we can talk about the NG (nasogastric) tube, if there is a need to provide something for a short-term. When NG tubes were brought into our practice, it was considered to be about a 30-day option. Some doctors will let this go between four and six weeks, but any time after that, it can actually cause some damage to the system. If the NG tube is in too long, you can actually erode ditches into the mucosa and you can cause strictures. Plus, both sphincters are open - the lower and upper - and you have a real issue with aspiration and reflux. In addition, many of the patients will extubate themselves. One good yank is all it takes and then we have to put it back down.
Some doctors will check the placement of the NG tube with an x-ray to make sure it is in the right spot. Sometimes they will do this using the stethoscope and hear a whoosh. Usually in my area they would do the x-ray. Sometimes the patient will cough vigorously, they will have emesis, and that is all it takes for that tube to be displaced. We need to always make sure that it is in the right spot. The other thing you will see with NG tubes is sometimes they will kink or coil and you will have multiple loops of the tube in the pharyngeal area. That is going to be extremely painful when that patient swallows, because every time the epiglottis inverts and comes back up, it is hitting not only one length of tube, but sometimes three if it is kinked and coiled. The NG tube is short-term. My doctors get antsy at the 4 to 6 weeks time frame.
