Coerced invasive procedures: Policy overriding indication in gastrostomy tube placement


Clinical scenario

An 83-year-old man is admitted with a hemiplegic cerebrovascular accident. He is found to have dysphagia, and a nasogastric feeding tube is placed. Over the next several days, his strength begins to recover, and he tolerates his tube feeding well. Discharge to a skilled nursing facility (SNF) for subacute rehabilitation is planned. His swallowing is showing signs of recovery; it has not recovered adequately but is expected to continue to improve such that he is predicted to be independent of tube feeding within 7-14 days. None of the facilities in the region are willing to admit a patient with a nasal feeding tube, despite the anticipated short duration. The patient is medically ready for discharge but is refusing the feeding gastrostomy. “Why would I want a hole in my stomach, if I’m only going to need it for 1-2 weeks and this tube in my nose is working fine and is comfortable?” he pleads with tears in his eyes.

Dr. Jane R. Cowan, administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York

Dr. Jane R. Cowan

Over the next several days he and his family are subject to numerous pressured conversations about tube placement, with well-meaning house staff explaining that his recovery from the stroke is dependent on transfer to the SNF and – erroneously – that nasal tubes are inappropriate for outpatient use. He extremely reluctantly assents to the gastrostomy, is discharged to the SNF, and is eating within 2 weeks. Subsequently the gastrostomy was removed at an outpatient appointment, and the gastrocutaneous fistula required wound care until it closed.

Dr. David S. Seres, professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center, New York

Dr. David S. Seres

Feeding dysphagic patients after stroke

Dysphagia, potentially leading to aspiration and/or pneumonia, is a common sequela of stroke – up to half of hospitalized patients are affected.1 When oral intake is contraindicated, patients are often fed by nasogastric tube (NGT) or by surgically or endoscopically placed gastrostomy tube (GT). Without good justification based on outcomes, NGTs are traditionally used when the need for feeding is thought to be short term (<4 weeks) and GTs are used for long term (>4 weeks). However, in 2005, a large multicenter randomized control trial found that the majority of stroke patients with dysphagia that would resolve had resolution within 2-3 weeks. Moreover, outcomes were equivalent or better for patients fed with an NGT versus GT.

The authors concluded by recommending feeding via NGT for 2-3 weeks, after which conversion to GT can be considered if dysphagia persists.1 Notably, the recommendation allows consideration, and no evidence-based guideline requires or recommends GT be placed based on duration of tube feed dependence. Currently, while nutrition and neurology authorities have adopted these recommendations,2,3 many authors have noted poor adherence to this guideline, and many find that the median period between stroke and GT placement is 7 days rather than the recommended minimum of 14.4,5,6 While ignorance can partially explain the lack of widespread compliance,6 the policies of posthospital facilities are another culprit. Increasingly, and for a variety of reasons unsupported by the literature, SNFs refuse NGT and require GT.4,7,8,9


Next Article: