[Dysphagia] Swallowing and dementia

[eripley at yahoo.com (Irene Campbell-Taylor)]

I'm afraid you'll find this scenario more often than we would wish. There are physicians who either don't know of the downside of enteral feeding or don't believe it. Many studies have demonstrated that they would never chose enterla feeding for themselves in similar cases but will prescribe it for patients. The real tragedy is that "doing everything" very often is doing harm. It is unethical for a physician to prescribe a treatment (and we finally have agreement that enteral feeding is a treatment) in which the potential hazards outweigh the benefits. Care ful spoon feeding of the palliative patient is not time consuming as they can usually take very little and that's find. they are offered only things they appear to like and only to the level they can tolerate. We aren't aiming for nutrition but comfort. These patietns are dying. they are palliative and the rule of palliation is comfort first and nothing invasive. 
I have found it distressing for many years and quit one job because of it. The medical director at the time who insisted that we do everything and anything the family wanted while knowing it was bad medicine, is now on the lecture circuit preaching the inappropriate use of enteral feeding in the terminally ill elderly. things can change but the process is often painful.
Irene.

Candace Grant <candaceg@vitelcom.net> wrote:
I am wondering if this is of concern to anyone else... Slowly over the past few years I have been getting more and more referrals in the acute care hospital for "swallowing" evaluations for patients who have this general history: either multiple strokes or probable Alzheimer's for many years, decrease in function over that period of time to bedbound, decrease in feeding ability. They enter the hospital for either "aspiration pneumonia" (yes, Irene!) or dehydration or a combination of the two. The question I am asked is: "Can Mrs. X swallow?" I usually find someone who has limited to no communication, severely to profoundly cognitively impaired, often contracted, maybe with pressure sores. At bedside, I find that they have poor oral stage abilities- inability to hold a bolus, inability to initiate a swallow, although once they do, they do a pretty good job. However, because trying to hand feed them is such a labor intensive task, the physician and family opt for an NG tube and maybe a
 gastrostomy. We have no palliative care physicians. If I recommend "careful hand feeding and excellent oral care", I get feedback that "We can't let them starve." I have given out all the articles I know of re: feeding tubes in advanced dementia, and seem to get nowhere. I saw two such ladies yesterday, and I work in a relatively small hospital. Our community has a belief that one must "do everything." There really isn't anything you all can do, but I am just wondering if anyone else has noticed this trend. It is as if medicine has lost all logic and common sense. Thanks.

Candace A. Grant_______________________________________________
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Dr I Campbell-Taylor
Clinical Neuroscientist
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