Imagine this: You’re about to be forced to have surgery because you’ve had a stroke, or other significant medical problem that makes it difficult to swallow. It is expected that you will be eating in a matter of weeks, but in the meantime you needed to be fed with a tube.
So, your doctors gently slid a thin feeding tube up your nose and down into your stomach, where it has been working comfortably for several weeks. Your stay in the hospital is coming to a close, but you still need some rehabilitation, which, when hospitalization is no longer needed, will happen in a nursing home. But, before you can be transferred, the nursing home demands that, instead of the nasogastric tube that has served you so well, you have a tube surgically implanted in your stomach — through the skin and wall of your abdomen — whether you want it or not.
Now, please disregard all the overblown and unethical hype regarding nasal feeding tubes being forced on Guantanamo prisoners as being painful torture. I can’t speak as to how it was done, there, but this is standard practice for comfortably feeding thousands and thousands of patients in hospitals, nursing homes, and at home throughout the world. There are 30 to 50 patients being fed with these temporary, non-surgical tubes on any given day in my hospital alone.
But because nursing homes in a number of regions of the U.S. are demanding them, patients are undergoing the surgical procedure to have these tubes inserted earlier and earlier in their hospitalization, and when patients are sicker and sicker simply to avoid delays in their eventual discharge to a nursing home because of this demand for surgical tubes.
In fairness, some of my medical colleagues are probably scratching their heads at why I would even raise this issue, let alone why I have argued that it is amoral (more to come on this). The invasive tubes are, after all, the preferred method for feeding in the long-term.
Well, when we asked the nursing homes why they demand the surgical tubes, the answers, which we’ve recently published, were quite distressing, because the scientific literature doesn’t support their claims.
We surveyed every one of the approximately 185 nursing homes in New York City, and also a large random sample from the rest of the country, and got responses from about 85 percent of each group. In New York City, roughly 80 percent of nursing homes have a policy that rejects nasal tubes and instead requires that patients have the surgical tubes for tube feeding, regardless of how long they may need them. In the rest of the U.S., only 35 percent of nursing homes won’t accept them. Mind you, this practice has become the dogma in other regions of the U.S. But when we see this kind disparity from region to region it clearly indicates that there are choices in how care should be provided.
And the reasons? Well, we were told time and time again that the nasal tubes are dangerous. They fall out, and patients can aspirate and die. We also heard that the tubes erode the nasal septum and cause bleeding. From the ferocity with which some oppose these tubes, which are standard of care, you’d think they are the work of the devil! And perversely fascinating, some of the supposed experts with whom we spoke mistakenly claimed that New York and Medicare both prohibit them! No. They don’t.
Here are the facts. First, neither New York nor Medicare prohibit the nasal tubes. In fact, they explicitly allow them. Second, while nasogastric complications do happen, they are relatively infrequent (see below). Third, published research does not support the contention that the nasal tubes are more dangerous than the surgical variety.
Certainly, as with any medical intervention, the nasal tubes do have complications, but not nearly as often as these nursing homes claim. Head-to-head studies have shown mixed results, but in the aggregate, neither type of tube is safer than the other. With the exception that the nasal tube might clog more often, there is no statistical difference.
Moreover, we monitored complications in our own patients. The adverse events were twice as frequent as, and far more serious than, those occurring in patients with nasal tubes. We found that 10 percent of people, both in our hospital and in other hospitals who had the surgical tube, died before they were discharged. No, they didn’t die of complications of the tube. They died because they were too sick to survive. So we may be placing these into people indiscriminately, doing non-beneficial, or even harmful surgical procedures on the sickest patients, because of external pressures from nursing facilities.
Here’s where this becomes an issue of morality. Nothing in medical ethics is more precious or more important than being able, as a patient, to determine what happens to your body. But patients in the regions where this misguided policy is prevalent are faced with having to either accept a surgical tube or not being able to get the care they need. We have many patients who are quite comfortable with the nasal tubes and are adamant that they don’t want the surgical version. But more often than not they succumb to pressure. And over and again, patients are eating and no longer needing a feeding tube in a matter of weeks, often before the surgical tube has healed well enough to be removed.
When visiting a loved one in a nursing home on the west coast, I found the director and asked about their policies related to nasal feeding tubes and whether they find these tubes problematic. The director looked at me quizzically. “Why should they be a problem? We put them in here at the bedside.”
Robbing patients of choice? Inflicting an unnecessary surgical procedure that results in unnecessary risk? Not the best of medicine. Wholesale refusal of temporary nasal feeding tubes, based on misinterpretation of policies and a lack of understanding of scientific studies, frankly equal to making serious medical decisions based on urban legend, must stop. A surgical feeding tube may be the right choice for some patients. But the choice must remain with the patient and their physicians, and be based on medical indications, not a lack of familiarity, or inaccurate beliefs.