There was an enormous outcry against the forced placement of temporary feeding tubes in the noses of prisoners on hunger strikes in Guantánamo. Dramatic and inaccurate representations of the tubes as torture appeared on the internet. We ethicists wrung our hands and worried as much about the rights of the prisoners as we did about the false message that was being delivered: that nasal feeding tubes are torture. But another kind of forced feeding, this one using an unnecessary surgical procedure, goes on unchallenged every day here in the United States. In some regions, this practice is simply an option, but in others it is adhered to with a nearly religious fervor.
Many patients have difficulty swallowing after a stroke or other severe illness. Recovery of swallowing is frequently possible, and sometimes rapid. But if eating is unsafe or too difficult for some time, a temporary feeding tube may be placed through a nostril and into the stomach. The tube, not much larger than a well-cooked piece of spaghetti, is gently inserted through the nostril using a lubricant. The procedure, which may sound awful, is in proper hands only minimally uncomfortable.
Once inserted, most of our patients find these tubes comfortable, and research has shown that these can be used for years. But based on data we have recently published, nursing homes in our region and elsewhere are refusing to allow admission of patients with these temporary, nonsurgical nasal tubes, requiring instead that a surgical procedure for the placement of a feeding tube be performed. These policies are inconsistent from region to region, do not consider the amount of time the tube is anticipated to be needed and are contrary to research that favors neither the surgical or nasal method. In New York City, we found that 80 percent of nursing homes refuse nasal tubes, compared to only 35 percent in a large random national sample.
A little medical background is in order. In my hospital-based practice, as mentioned, nasal feeding tubes are used quite commonly and comfortably. But for patients needing longer-term feeding, a surgically placed tube, often referred to as a PEG, is generally favored. Believed to be safer, more comfortable and more secure, the surgical tubes may be placed by a gastroenterologist, using a scope, under sedation and local anesthesia, sometimes even in the sickest of patients. Research, however, has not demonstrated that these are safer, more comfortable or more secure. In fact, based on our data, the incidence of adverse events associated with these tubes is twice as frequent as, and are often far more severe than, those occurring with the nasal tubes.
Nasal tubes are not without their problems. In some patients, they are indeed uncomfortable. They can be inadvertently inserted into the lungs, can cause erosions or bleeding in the nose, and can be accidentally pulled out with some ease. These are some of the reasons given by the nursing homes for refusing them. But the surgical tubes are also prone to similar problems. They are often accidently pulled out. Our surgical consultation team reports several weekly trips to the emergency room to deal with this problem, which may lead to such problems as severe infections of, and gaping holes in, the abdominal wall. Additionally, methods for securing the nasal tubes makes their dislodgement much less frequent, and there are reliable methods for insuring safe insertion, so these should not be deterrents to their use.
In biomedical ethics, no single concept is more important than patient autonomy: the ability to determine what happens to one's body. Moreover, we clinicians all commit to doing no harm. While clearly motivated by fear of harm from the nasal tubes, misguided nursing home policies — rather than medical indications — are driving practice. Because of the rigidity of these policies in the effected regions, tube-fed patients needing nursing-home care cannot be discharged from the hospital unless the surgical tube is placed. The patients, their families and those caring for them in hospitals face a distressing moral dilemma: force an unnecessary surgical procedure on the patient or face not being able to discharge them from the hospital.
This practice is driving changes in care throughout hospitalization. The medical literature is full of reports of patients undergoing the insertion of the surgical tube while critically ill in an intensive care unit to avoid prolonging the hospital stay, since it is anticipated that the patient will need to be discharged to a nursing home unable to eat at some point in the future. In published reports, including ours, somewhere around 10 percent of patients who have the surgical tube inserted do not survive to discharge. In one study from Penn State University and Johns Hopkins University, most of the surgical tubes had been removed before the surviving patients were even discharged from the hospital. The mortalities are not due to complications of the procedure. But the high death rate and removal before discharge underscore that there are pressures to insert too many of these tubes.
In fairness, the medical directors of several of the nursing homes in our network have agreed to work toward improving the skills of their nursing staff such that they can accept the nasal tubes. But they lack funding for the training, and are unable to prioritize making these changes.
In discussing this issue, I have been berated by organizations representing nursing homes and told I am going to kill people. New York State Department of Health policy expressly permits the use of nasal tubes for upwards of three months, but has been frequently misquoted to me as outlawing them. And well-informed colleagues have politely disagreed, citing how uncomfortable the tubes are. But I cannot ignore the countless patients who tell me otherwise, and who could have avoided the procedure. We are often faced with transferring patients to nursing homes who are adamant that they be allowed to retain the nasal tube rather than undergo the surgical procedure. They perceive the nasal tube as comfortable, and often the expectation is that it will be needed to be used only for another two weeks. But bowing to pressure, our patients most often allow the tube to be placed. Many are eating well in two to four weeks, sooner than the tube can even be removed as it hasn't fully healed.
My mother required a short stay in a nursing home in Portland, Oregon. When visiting her, I sought out the director. "What is your policy," I asked, "about nasal feeding tubes? Do they present a problem?."
"Why should they be a problem?" she asked. "We place them here at the bedside."
Seres, M.D., is director of medical nutrition, associate professor of medicine and an associate clinical ethicist at Columbia University Medical Center, New York Presbyterian Hospital.