Assignment: Feeding tube w/dementia patient

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I'm working on a group project and I think we're stuck. The hypothetical patient has advanced dementia such that she cannot recognize family members and has been hospitalized numerous times. She has no advanced directive and is incapable of making medical decisions. She is in skilled nursing following a hospitalization for aspiration pneumonia. She had a j-tube placed, approved by her husband (and caregiver) who was under the impression that it was a temporary measure and not meant to be life-long. She is becoming increasingly combative- part of which is due to her desire to eat and being NPO. Her quality of life has become quite poor and she is unable to perform ADL's independently. The distraught husband has expressed interest in assisted suicide. In Oregon we do have Death with Dignity, however she is not elligible due to her advanced dementia. My own research has indicated that artificial nutrition and hydration for patients with advanced dementia causes more harm than good.(https://sites.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/ANOREXIA%20AND%20WEIGHT%20LOSS/Pegs%20dementia%20editorial.pdf)

It is my understanding that the nurse cannot stop tube feeding without the patient requesting it- something that cannot happen. I feel that continuing tube feeding is causing harm to the patient, but who can make the decision to stop feeding? What does the law say? I have been at this for hours and I have no idea how to proceed. Any hospice nurses out there to save me??

Specializes in Pedi.
@amolucia,

Bridled means that the patient will go into interventional radiology to have the NGT wrapped around into the septum. It's less likely for the tube to get dislodged/removed; but, if the patient pulls hard enough, they will be bleeding a lot. ;o

AMT Bridle Family | Nasal Tube Retaining System & Pediatric

I have never seen or heard of this and I send patients home with NG tubes on the regular.

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That's interesting. How long have these been in use? Are there any studies about pressure injury inside the nose?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
That's interesting. How long have these been in use? Are there any studies about pressure injury inside the nose?
Nasal Bridles for Securing Nasoenteric Tubes: A Meta-Analysis
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Specializes in SICU, trauma, neuro.

I work in ICU, vs long-term, but families make the choice to transition their loved ones to comfort care all the time. Part of comfort care is d/c'ing tubefeeds, fluids, and any meds that have no comfort-enhancing purpose (antibiotics, BP meds, etc.)

Dementia is terminal. This hypothetical husband as (I'm assuming) her decision maker can absolutely choose a palliative care consult.

Also, re: the NPO status. I'm not sure how that works with someone with dementia, but people who understand the risk of aspiration can absolutely eat if they want to. Years ago I cared for a 90 yr old with a GT due to his aspiration risk. He was to return to his AL apartment when he could administer his own tubefeeds. Well he never got the hang of it, and was very clear that he wanted to eat. He was aware that by eating he was risking his life; he decided that a life without pie and coffee was not worth living. So he had pie and coffee, was discharged home with a palliative consult, and died a week later.

Again someone with dementia can't exactly say "I understand that my food can get into my trachea which can be painful and cause pneumonia." So I don't have a clear answer in your case. That is something that can be addressed in an ethics conference and in her interdisciplinary care conference.

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Specializes in retired LTC.

Thanks for the info re 'bridles'. I heard about something like that once, but it was eons ago.

In LTC, the permanent surgical kind are the tubes of choice. It was super rare to have an NGT.

My biggest issue was with facilities who deliberately utilized foley caths as GTs, not true Flexi-flows. It was a cheap effort at cost control but I always found them prone to migration (regardless how securely we tried to anchor them). There were always problems.

On the exterior paper wrapper of foleys, there was a phrase "for UROLOGICAL USE ONLY". Liability anyone???

Sheesh!

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Specializes in Burn, ICU.

Bridled means that the patient will go into interventional radiology to have the NGT wrapped around into the septum. It's less likely for the tube to get dislodged/removed; but, if the patient pulls hard enough, they will be bleeding a lot. ;o

We don't take them to IR, we just place the bridle after the position of the tube is confirmed by an Xray. The bridle doesn't require an Xray...you either can get the stylets to stick together, or you can't and someone else tries.

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Specializes in retired LTC.

I just shivered again as I 'ouched' just thinking about tugging on that bridle and the nasal septum.

I would NEVER give consent for that! Ooww!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I just shivered again as I 'ouched' just thinking about tugging on that bridle and the nasal septum.

I would NEVER give consent for that! Ooww!

It isn't the bridle itself...that is the term. Two short catheters are inserted in each septum and attach by magnet. One is removed and the other is slowly removed that has a "string" the string is then secured externally.
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Specializes in Burn, ICU.

OP, sorry we've sidetracked your thread!

re: bridles, out hospital just started using them a year or so ago. To be clear, the stylets are inserted in each nostril, click together behind the vomer bone (not just around soft tissue...for good or for bad, and no, there's no way to assess this internal site for pressure injuries w/o a scope), and then a piece of flat twill tape is pulled through from one nare to the other. The stylets and magnets are removed. A special clip clips around the twill and the tube and holds it in place. Certainly if you pull on the tube hard, I bet it hurts. On the other hand, if a pt pulls out a tube with the usual "sticker" that tapes it to the nose, they have to get the tube replaced and get an Xray, delaying feeding and certainly causing discomfort. NGTs are not long-term solutions and neither is the bridle, but I think it can minimize problems when used correctly. For our patients with facial burns, for example, the stickers don't stick anyway!

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