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Short-term Versus Long-term Options for Alternate Nutrition and Hydration

Denise Dougherty, MA, SLP

March 27, 2017

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Question

What are the short-term versus long-term options for alternate nutrition and hydration?

Answer

Short-term Options

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. 

Long-term Options

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.


denise dougherty

Denise Dougherty, MA, SLP

Ms. Dougherty owns a private practice in Indiana, PA.  She has worked with clients from the Northeast US and overseas. She is a past President of the American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA), received the Academy’s 2007 Honor Award and AAPPSPA Award of Excellence in 2014. Denise is a co-editor of a new book, Private Practice Essentials: a Practical Guide for Speech-Language Pathologists published by ASHA Press.   She served on the ASHA Health Care Economics Committee and is a member of the Technical Experts Panel for Quality of Insights of Pennsylvania, working on initiating quality measures for CMS to improve effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries. Denise works as a legal consultant/expert witness in litigation involving negligence, malpractice and wrongful death. She received her bachelor’s degree in communication disorders from Marywood University in Scranton, Pennsylvania; and a master’s degree in communication disorders from St. Louis University.  Ms. Dougherty is a member of the Pennsylvania Speech and Hearing Association, and the American Speech and Hearing Association. 


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