Forms of artificial nutrition and hydration:   gastrostomy   nasogastric
intravenous   TPN
A Consumer and Caregiver's Guide
http://www.dickinson.edu/endoflife/MedicineTubes.html

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.