Gastrostomy Tube (G-Tube);
Percutaneous Endoscopic Gastrostomy (PEG tube);
Jejunostomy Feeding Tube (J-Tube)

Procedure:  Gastrostomy tubes are the preferred method of artificially feeding and hydrating patients over the long term.  Gastrostomies, first practiced on humans in 1875, involve the surgical insertion of plastic tubes into the stomach through the abdominal wall.  J-tubes, are similar to G-tubes, but are much less commonly used for patients at the end of life.  J-tubes feed into the upper intestines rather than into the stomach.  With both G-tubes and J-tubes, a track forms between the skin and the stomach wall over time (much like the track that forms in the ear lobe a few months after ordinary ear piercing).  The tube can be relatively comfortable after the incision heals.

Possible complications of Gastrostomies:

• Wound infections and painful insertion sites (where the tube passes though theskin), hemorrhaging and splitting open of the incision site.
  
  
• Inflammation of the stomach lining (peritonitis), stomach wall perforation and other related stomach and stomach wall defects, diarihea, gastrointestinal bleeding, bowel obstruction, nausea, vomiting, reflux, fluid overload.
  
  
• Aspiration of feeding formula into the lungs, leading to aspiration pneumonia.
  
  
• Patients who are at least partially conscious may be confused and irritated -- physically and/or emotionally -- about the purpose of the stomach tube and its associated apparatus.  Patients suffering from dementia may need to be restrained (physically and/or using drugs) so that they do not inadvertently dislodge or purposefully pull the tube out.  (This is most likely during the two weeks after tube placement, when it is especially important that the tube not be disturbed.  Restraints are less likely to be needed after that.) 

Citations

Finucane, Thomas E., Christmas, Colleen, and Travis, Kathy.  1999.  "Tube Feeding in Patients with Advanced Dementia," Journal of the American Medical Association.  Vol. 282, pp. 1365-1370. 

Major, David. 1989. "The Medical Procedures for Providing Food and Water: Indications and Effects." In Joanne Lynn, ed.,  By No Extraordinary Means: The Choice to Forgo Life Sustaining Food and Water.  Bloomington, Ind.: University Press, pp. 21-28.

Peck, Arthur, Choen, Camille E., and Mulvihill, Michael N.  1990.  "Long-Term Enteral Feeding of Aged Demented Nursing Home Patients," Journal of the American Geriatrics Society. Vol. 38, pp. 1195-1198.

Nasogastric (NG) Tube

Procedure:  Feeding by NG tube is the most common mode of delivering feeding formulas directly to the stomach for patients who need assistance in the short term.  The insertion of an NG tube involves the passing of a flexible plastic tube, lubricated with a tasteless jelly, up through the nostril, then down through the back of the throat and into the stomach. NG tubes are rarely used for incompetent patients.

Possible complications of NG Tubes:

• The process of NG tube insertion can be quite uncomfortable, and even painful, especially when the tube hits the upper portion of the nasal cavity (when the individual doing the insertion must force the tube to make the downward turn toward the throat).  Then, as the tube passes down past the esophagus it often causes a gag reflex that can result in vomiting.
  
  
• For confused patients, tube insertion can be frightening, requiring that they be physically restrained during the insertion.  Even after the tube has been placed, it can be irritating and frightening to the demented patient, forcing care givers to put the patient's hands in mittens which are tied to the sides of the bed or chair, to prevent them from tampering with the tube.
  
  
• If formula is introduced into the stomach too rapidly, diarrhea, regurgitation, aspiration, or vomiting can result.
  
  
• If the NG tube becomes dislodged (or if the patient vomits), gastric contents can be aspirated into the lungs, leading to the development of aspiration pneumonia.
  
  
• The placement of NG tubes is often considered part of routine care that is consented to on admission.  Only rarely do hospitals require the specific consent of the patient or surrogate, raising concerns regarding tient and surrogate autonomy.

Citation

Finucane, Thomas E., Christmas, Colleen, and Travis, Kathy.  1999.  "Tube Feeding in Patients with Advanced Dementia," Journal of the American Medical Association.  Vol. 282, pp. 1365-1370. 

Office of Technology Assessment (OTA). 1987. Losing a Million Minds: Confronting the Tragedy of Alzheimer's Disease and Other Dementias.   Washington, DC: U.S. Government Printing Office, July.

Intravenous (IV) Line

Procedure: The intravenous (IV) line is the most common method of delivering nutrition and hydration to patients over the short term.  This method, first employed in the 1890s, can be used to supply a patient with water, saline, glucose solutions and medications which are infused through a needle inserted in the patient's arm or leg.  It is difficult and expensive to supply full nutrition via intravenous feeding over an extended period of time.  Consequently, it is typically used over the long term only when the gastrointestinal tract is blocked or diseased to the point where absorption of food and fluids is compromised. 

Possible complications of IV lines:

• Infection at the placement site of the IV needle.
  
  
• Placement of IV lines is often considered part of routine care that is consentedto on admission.  Only rarely do hospitals require the specific consent of the patient or surrogate to begin IV feeding and hydration support. This practice raises concerns regarding patient and surrogate autonomy.

Citations

Hastings Center.  1987. Guidelines on the Termination of Life-Sustaining Treatment and Care of the Dying.  Briarcliff Manor, N.Y.: Hastings Center. 

Office of Technology Assessment (OTA). 1987. Losing a Million Minds: Confronting the Tragedy of Alzheimer's Disease and Other Dementias.   Washington, DC: U.S. Government Printing Office, July.

Total Parenteral Nutrition (TPN)

Procedure:  Total parenteral nutrition (TPN) was developed in the late 1960s and widely applied beginning in the 1970s.  It provides an alternative to the IV line for patients who need to be artificially fed over the long term but cannot tolerate stomach feeding.  With TPN, formula is fed into the body through a catheter which is inserted into a large, central vein in the patient's chest or neck.  TPN is very expensive and almost never used in patients near the end of life. 

Possible complications of TPN:

• TPN patients run a significant risk of catheter- and formula-related infections.
  
  
• Mechanical problems with insertion and maintenance of the catheter have also been noted.
  
  
• As with any form of tube feeding, confused patients may have to be physically or chemically restrained to prevent them from tampering with the TPN line. 

Citation

Office of Technology Assessment (OTA). 1987. Losing a Million Minds: Confronting the Tragedy of Alzheimer's Disease and Other Dementias.   Washington, DC: U.S. Government Printing Office, July.