What are the short-term versus long-term options for alternate nutrition and hydration?
With artificial nutrition and hydration, we usually have the choice of an NG tube versus the PEG tube. NG tubes are generally placed when a patient has initial dysphagia from a stroke or when the swallow begins to have some difficulties. The placement for an NG tube is usually short-term, about a 30-day timeframe. Some doctors will let it stay in place for six to eight weeks, and I have actually seen patients who have had them in place for months. This can actually cause significant difficulties. There can be reflux because the two sphincters are open, and a stricture can actually occur from an NG tube being in for too long. NG tubes are easy to extubate and this can happen with patients. Additionally, positioning of the tube must be monitored during feeding because of the incidence of reflux.
For more long-term options, the PEG tube is traditionally used. There is also a J-tube which is the preferred method when dysphasia therapy has not made a difference in creating a safe swallow in a short amount of time.
When dysphagia occurs, especially after a stroke, typically the NG tube is placed first. Then we do try some therapy. The PEG might be placed if we haven’t worked on the swallow to make it safe. However, in many parts of the country, because patients are now transferred very quickly, many facilities will not admit a patient if they have an NG tube. As a result, many PEGs are being placed relatively early which goes against what the literature suggests is safe. Some studies state that they should not be placed up to 30 days after the initial insult because of the high mortality rate in the first 30 days.
When considering choices to alternative nutrition and hydration, patients have short-term options, long-term options or patients can say “thanks but no thanks”. Often, it comes down to quality of life for patients. Many of you have probably had patients and families who have said that eating is their loved one’s last pleasure in life. They want them to eat regardless of the consequences. It really is the patient and the family’s decision. We can make recommendations, educate and answer questions because we want this to be an informed decision for the patient and/or family. But we cannot force them into any one decision. We need to be sure we are providing them with options.
Please refer to the SpeechPathology.com course, Decision Making for Alternate Nutrition and Hydration, Part 1, for more in-depth information on concerns that impact the decision-making process for patients and families, such as religious beliefs and culture.