Aspiration: Help request

[catlvr]

Hi, I work in LTC, and we have a gent with advanced dementia (full code, *sigh*) who we suspect has been aspirating on his puree food and honey thick liquids. He coughs when eating, but remains afebrile. Lung sounds are rhonchi in the upper lobes, and they usually clear with a duoneb treatment. The CNAs refuse to feed him; I feed him dinner. The day nurse said that they feed him until he coughs - a few bits and sips - and then they stop. He opens his mouth continually for food when you are feeding him or even address him, so I suspect that he is hungry; I feed him the entire meal, since I figure that I'm damned either way: we give him far too little intake, or he aspirates.

His family does not want a feeding tube (thank goodness!), but refuses to make him a DRN. They said that if we do so, we will let him die. We've sent him to the hospital three times in the last six months with aspiration pneumonia.

Any tips that might help to keep this gent as safe as possible? We feed small amounts at a time, slowly, keeping him upright for at least 30 minutes post meal.

TIA,

e

[SuesquatchRN, BSN, RN]

Hospitalized how many times in the last 6 months? Plus dementia...that's enough for an admission to Hospice.

We have one who is hospitalized more than not, his family keeps insisting we do "everything," and because it's AD we can't do a medical futility.

[tewdles, RN]

If I am not mistaken, the medicare guidelines indicate that dementia of 7b on the FAST scale is indicative of a life expectancy of 6 mos or less (it could be 7d, I am one cocktail into my evening and don't have the book in front of me). Couple that with recent hospitalizations, pneumonia or upper urinary infections or abundant co-morbidities and you have a hospice appropriate patient. Of course, the family would have to agree...which seems unlikely in this case.

In terms of feeding vs. not feeding...until the physician and facility make it "safe" for a nurse to participate in an activity that is KNOWN to cause the patient distress and potential harm, that nurse is well within his/her rights to refuse to participate....protection of the patient AND the license is imperative. Given that this family is obviously having difficulty processing information in a realistic fashion I might not be willing to jeopardize my livelihood on the assumption that they won't get ornery when the old guy ends up intubated and in critical care because of an aspiration event during MY meal time.

[SaltyNurse]

The peg-tube folks we have suffer as much aspiration as do those eating PO. The choice is to starve a hungry man a/e/b his opening his mouth and avidly eating because you don't want to risk him aspirating or putting in a tube with which he will also aspirate.

At this time, I'm not able to look up the study you cited earlier in the thread. I do have access to CINAHL and Pubmed at work, but do not have the time during my shift and due to family responsibilities, cannot hang out afterwards in order to peruse the latest research, so I appologize for not being able to make the follow through to actually look at these studies.

If studies are finding that aspiration pneumonia rates are not statistically lower in subjects that receive PEG tube feeding versus those that are fed orally, there are other factors to be examined before concluding that PEG feeding is not any safer. Just to name a few, there are continuous vs. bolus feedings, maintaining head of bed elevation, G vs. J tubes, gastric reflux disorders, gastric emptying disorders, not to mention the variations in patient populations and variations in types and degrees of dysphagia. Furthermore, aspiration pneumonia can occur in those that aren't receiving any oral/enteral nutrition at all, simply for the fact that some patients aspirate their own oral secretions and the only intervention that can *attempt* to mitigate that is meticulous oral care. Unless there is solid, replicated research that accounts for these other variabilities and still shows no difference in outcomes, I'm dubious about concluding that oral feedings are just as safe/dangerous (in regards to aspiration) as PEG feedings.

Anyway, that's my thought process for what it's worth. Sorry it took so long to respond. I've been crazy busy

[SaltyNurse]

Feed him he dies- do not feed him he dies...hummmm...If it were me, please feed me so I would at least die with a full belly...

seriously- I would talk again with the family and have them sign a form that releases the facility of the liability associated with feeding him, and then feed him. If people are afraid to feed him then he is going to die of malnutrition...that sounds like a bigger problem than aspiration to me.

I hesitate to make a judgment call about whether death by starvation or death by sepsis and/or ARDS on a vent is worse. From a license standpoint, I can defend my decision not to orally feed a patient when I have sufficient reason to believe I would be harming him/her by causing aspiration. Particularly when other routes of nutrition, though not without risk, but still in my estimation are safer, are available. The decision to "starve" the patient by refusing enteral nutrition (in this situation) would be on the family, not on me. And there is a noteworthy lapse of logic for a family to refuse an enteral tube and yet insist that when this patient's respiratory efforts fail (as will inevitably occur), an invasive tube should be inserted for the purpose of delivering supraoxygenated air under pressure to sustain life- during which time, the patient will require enteral nutrition (if his hypoxic gut can handle it) in order to have a hope for survival. It's the same kind of misguided thinking that goes into "partial code" status (i.e. injecting epinephrine into a peripheral vein and.....*hoping for diffusion?* since you can't circulate the drug to the heart because compressions are gruesome).

And it doesn't help that we (nurses and doctors) are too much of a pansy-*ss to really educate people. We end up catering to their misguided and ill-conceived notions much to the detriment of the poor sucker on the wrong side of the vent.

[VeronicaWileyRN]

This gentleman does sound like he is aspirating. Have you had a speech therapist work with him to at least give the staff suggestions on how to feed this man. I would also suggest that the physician along MDS nurse go over with the family about DNR and that putting someone on a DNR doesn't mean that you will allow him to die. I have worked with Hospice in NC several times and someone can be admitted to hospice with just a diagnosis of advanced Alzheimers. You need to let the family know that eventually he will stop eating and what will they want to do then? Alzhemiers is a terrible thing to have.