NPO and G Tube Feeding:
What’s A Clinician To Do?
By Guest Blogger: Yvette McCoy, MS, CCC-SLP, BCS-S
Edited by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
The American Speech-Language and Hearing Association’s (ASHA) 2014 convention inspired us. Here is Yvette McCoy’s summary of a session by Dr. Towino Paramby of the University of Central Arkansas and Dr. Paula Leslie of the University of Pittsburg
Paramby, T. & Leslie, P. (2014, November). 1135: Tube Feeding & the SLP’s Scope of Practice. Seminar presented at the annual convention of American Speech-Language-Hearing Association, Orlando, FL.
We all like to have OPTIONS!
I often find myself sifting through the convention planner at ASHA trying to juggle which sessions I want to attend. I want sessions that will challenge my current way of thinking about what I do in treatment. When I saw Dr. Towino Paramby and Dr. Paula Leslie’s session on feeding tubes and the role of the SLP , I was immediately intrigued.
How many times have we as clinicians recommended that a patient be NPO?
Should we recommend NPO?
What exactly is our role in this area of our practice?
You have just received an order to “evaluate and treat for dysphagia.” You complete the evaluation and determine the patient is not safe to eat or drink by mouth. What is your first recommendation? What should you recommend? For guidelines regarding our scope of practice, Paramby and Leslie point to The American Speech Language Hearing Association (2002 ): Knowledge and Skills Needed by SLP Providing Services To Individuals With Swallowing and/or Feeding Disorders.
To Tube Feed or Not To Tube Feed?
We know that the sole purpose of tube feeding is to offer nutrition and hydration. (Note: tube feeding is used to refer to alternative nutrition given via a tube. It may be called NG tube feeding if the tube is placed through the nose. When the tube is placed into the stomach through the skin it is called PEG tube feeding or G tube feeding.) What else does tube feeding have to offer? Does it prevent aspiration? Does it result in prolongation of life? Does it improve quality of life? These are the questions that we should be asking ourselves as clinicians. Studies have shown that tube feedings do not prevent aspiration, and in some cases may cause increased aspiration. It does not result in prolongation of life, and quality of life is subjective. We as clinicians can not determine what the patient’s quality of life will be. The belief that withholding food and hydration causes suffering is NOT supported by research. The placement of a tube is often driven by family concerns, and not by an fully informed decision-making process. Eating is associated with good health in our society and taking that away is mistakenly often seen as “starving the person to death.” As the body is trying to shut down, a natural loss of appetite occurs, as well as decreased sensation. Tube feedings can interfere with the body’s natural process of “shutting down”.
Tube feedings can be beneficial in the acute phases of illness for brief periods of time when the patient may not be able to safely take enough nutrition and hydration by mouth.
Research demonstrates that G tube feedings are NOT helpful in patients who are terminally ill with end-stage cancer, COPD, and dementia.
Dr. Leslie notes: “We (SLP’s) need to have knowledge of the appropriate tube feedings available, but nowhere does it say that we should be the ones making the decision.” Our role is to talk about the increased risk of aspiration, to educate staff/patients/families, and to assist the medical team in guiding informed decision-making.
What are the risks associated with tube feedings?
Paramby and Leslie point to the following as the most common:
- Reflux
- Nausea/vomiting
- Diarrhea/constipation
- Malabsorption/maldigestion
- Aspiration
- Tube malposition
- Tube clogging
Other risk factors: increased need for restraints and sedation, as well as an increased risk for C-difficile infection.
Expectations versus Outcomes
In a survey (Carey, et al, 2006), 90% of families expected that G tube feeding would correlate with the following positive results:
- Better quality of life
- Longer life
- Better health
However, after tracking the patients at 3 and 6-month intervals, the study showed very different real outcomes with G tube feedings:
- No change at all in activities of daily living (expectation of better quality of life)
- No change in percentage of patients admitted to nursing homes (expectation of better quality of life)
- 30% had a 6-month mortality rate (expectation of longer life)
- No change in decubitus ulcers (expectation of better health)
Dr. Leslie suggests: “Do not write NPO”, as this can often lead the physician to recommend tube feedings (i.e., via an NG tube or a G tube) without careful discussion with the patient/family. Dr. Leslie encourages clinicians to give options based on the findings, with one option being: “recommend consideration of supplemental nutrition.” We should give facts based on OUR scope of practice. We can advise as consultants. Our job is to support the medical team as consultants, using facts to support “why” we are making specific recommendations. Another very important role is to educate the patient/family by teaching the mechanics of protecting the airway and discussing the risks versus benefits versus outcomes.
As speech-language pathologists, we play a very important role in the assessment and treatment medically fragile patients with swallowing difficulties. Our clinical decisions have a significant impact on the patient’s health and quality of life. Let us be judicious in our recommendations, considering all aspects of the patient’s condition, as well as familial concerns.
I will be thinking very carefully the next time I make a recommendation that may include an “alternate method of nutrition.”
What will your recommendations include?
Keep this conversation going and read more about The SLP’s Role in Palliative Care.
References Associated With This ASHA Session:
American Speech-Language-Hearing Association. (2002). Clinical indicators for instrumental assessment of dysphagia. Retrieved September 29, 2012, from https://www.asha.org/policy/GL2000-00047/
American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders. Retrieved September 29, 2012, from https://www.asha.org/policy/KS2002-00079/
American Speech-Language-Hearing Association. (2004). Preferred Practice Patterns for the Profession of Speech-Language Pathology. Retrieved October 4, 2010, from https://www.asha.org/policy/PP2004-00191.htm
Anis, M., Abid, S., Jafri, W., Abbas, Z., Shah, H., Hamid, S., et al. (2006). Acceptability and outcomes of the Percutaneous Endoscopic Gastrostomy (PEG) tube placement: Patients’ and care givers’ perspectives. BMC Gastroenterology, 6(37).
Asha, N.J., Tompkins, D., & Wilcox, M.H. (2006). Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficile, Clostridium perfringens, and Staphylococcus aureus. Journal of Clinical Microbiology, 44(8), 2785-2791.
Bliss, D.Z., Johnson, S., Savik, K., Clabots, C.R., Willard, K. & Gerding, D.N. (1998). Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med., 129(12), 1012-1019.
Carey, T. S., Hanson, L., Garrett, J. M., Lewis, C., Phifer, N., Cox, C. E., & Jackman, A. (2006). Expectations and Outcomes of Gastric Feeding Tubes. The American Journal Of Medicine, 119(6), 527.e511-527.e516.
Curtis, J. R., & White, D. B. (2008). Practical guidance for evidence-based ICU family conferences. Chest, 134(4), 835-843.
Hughes, J., & Baldwin, C. (2006). Ethical Issues in Dementia Care: Making difficult decisions. London: Jessica Kingsley Publishers.
Lawrence, S.J., Puzniak, L.A., Shadel, B.N., Gillespie, K.N., Kollef, M.H., Mundy, L.M. (2007). Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure. Infect Control Hosp Epidemiol, 28(2),123-130.
Lee, J., Tse, S., Tsze, S., & Kwok, T. (2004). Protein Malnutrition is adversely associated with swallowing recovery in tube-fed older people (letter). JAGS, 52(9), 1588-1589.
Marks, M., & Arkes, H. (2008). Patient and surrogate disagreement in end-of-life decisions: can surrogates accurately predict patients’ preferences? Med Decis Making, 28(4), 524-531.
Meier, D., Ahronheim, J., Morris, J., Baskin-Lyons, S., & Morrison, R. (2001). High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Arch Intern Med, 161, 594-599.
Mitchell, S. L., Kiely, D., & Lipsitz, L. (1998). Does artificial enternal nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? Journal of Gerontology: Medicial Sciences, 53A, M207-M213.
Teasell, R., & Foley, N. (2005). Results from the FOOD trial. The Lancet Neurology, 4(5), 267-267.
The FOOD Trial Collaboration. (2005). Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): A multi-centre randomized controlled trial. The Lancet, 365(9461), 764-772.
Veldee, M. S., & Peth, L. D. (1992). Can protein-calorie malnutrition cause dysphagia? Dysphagia, 7(2), 86-101.
Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Diet, 18(3), 213-219.
THANK YOU
GUEST BLOGGER:
Yvette McCoy, MS, CCC-SLP, BCS-S is a speech-language pathologist with over 22 years experience, specializing in adult-neurological rehabilitation with a special interest in dysphagia and stroke rehabilitation. She is a Board Certified Specialist in Swallowing and Swallowing Disorders. She owns Speak Well Solutions, LLC, a thriving practice started in 2005 that now has four employees. She is certified by the American Speech-Language-Hearing Association, and a four time ACE Awardee. She is also a member of the Dysphagia Research Society and is an MBSimP registered clinician. She currently serves on the Adult Services Committee for the Maryland Speech-Language and Hearing Association, as well as on the Website, Communications and Public Relations Committee for The Dysphagia Research Society. She obtained a Bachelor of Science Degree in Speech Pathology from Northeast Missouri State University in 1990. (now Truman State University) In 1991 she earned a Master of Science in Speech Pathology from Southern Illinois University at Edwardsville. Follow her on Twitter @yjohnsonmccoy, and connect with her on LinkedIN or visit her website at www.speakwellsolutions.com
Can the speech therapist perform trial feedings for a pt. with NPO status?
Audrey,
Thanks for question.
If you get a bedside swallow evaluation on a patient whose orders are currently NPO, you should check with the MD/NP/PA who placed the order to make sure she/he is okay with you testing a few items. Likely, the pt is NPO due to aspiration risks, awaiting SLP recs for upgrading the diet. The order may indicate this.
Potentially, the patient is NPO due to GI issues. Therefore, you really need to double check with MD. Maybe the patient can only have trials of clear liquids if it is a GI issue. This is up to the MD.
Another example, if the patient’s aspiration issues were due to small bowel obstruction and vomiting, the patient may require NGtube on “low-wall suction.” You will see an NGtube in the patient’s nose and liquids coming out on suction. Then – you really can’t do any po trials!! This is an extreme example, but an immediately visibly obvious one.
I like to always let the nurse know that I will evaluate the patient’s swallowing before I start the exam, and the nurse can let us know if there is any other contraindications to trying po. Maybe the nurse will say, “Oh no, that patient was really agitated and just got medicated with Ativan. Don’t give her anything now!”
Ultimately if the patient has been NPO for a day or more, check the mouth thoroughly before giving anything. The potential for poor oral hygiene is high. Clean mouth. Maybe start with ice chip trials if the patient is managing secretions well and alert.
Feel free to keep asking questions. Hope others will add to this discussion too.
Karen
SwallowStudy.com
Hello,
Thank you for the valuable article,
If the patient not safe for any oral feeding and he had silent aspiration with positive history of aspiration pneumonia, could I recommend tube feeding in this case?
That is a question that requires an answer with many caveats. This would depend of course on the patient’s goals of care. See also the blog on palliative care: https://swallowstudy.com/?p=623
There are also additional considerations of the underlining medical diagnoses. For example, a person with head and neck cancer with chronic dysphagia from late-radiation induced dysphagia may tolerate some aspiration and want to stay on a least restrictive diet.
Conversely, a person with an acute stroke may be at high risk for aspiration pneumonia and the prevention of negative sequela from aspiration may be paramount.
Additionally, a person can still get aspiration pneumonia from tube feeding – which may only elevate the risk for aspiration pneumonia is some patients – especially in bedridden patients who are dependent for oral care.
There are many things to learn, so much
information on it. Your blog really inspires me a lot.
Best regards,
Mead Henneberg
Is it within the SLP scope of practice to physically stop the ng tube feedings if while working with the patient they demonstrate increased secretions and increased risk of aspirations, particularly when the SLP needs to suction the patient and noticed tube feeding colored material suctioned from the or is the Nurse the only one who is to come to the bedside to actually physically turn of the ng tube feedings? Please advise.
Thanks
This sounds like an urgent patient safety situation. You would press “hold” temporarily on the machine, but immediately get nursing (which may even require yelling out to the hallway, as this sounds serious and you will need to stay with the patient for safety – making sure the head of the bed is up and encouraging cough/swallow, while suctioning with a Yankauer oral suction device). If you are specifically trained in deep suctioning, you can do this immediately; however, that deep suctioning requires competency verification after training. Once the emergency is passed, yes, it is typically the nurse who manages the turning on/off of tube feedings or adjusting rates per the dietitian and physician.
Regarding the event: Document carefully the event: time you noticed issue, what you observed, your actions and timing of getting help immediately, and the resolution. It is so important to have clear documentation of a witnessed aspiration event, as that helps the physicians guide the next actions and to watch for signs of a pneumonia brewing. Additionally, it helps focus the cause of aspiration on tube feedings rather than someone thinking it was the person’s oral feeding trials or your evaluation that lead to pneumonia. NGtubes have high risk for getting looped, dislodged, or the patient may inadvertently partially pull it out. If it is still running when pulled partially out, then the tube feeding could be running into the pharynx or upper esophagus, thereby causing gross aspiration (in large quantities). In general, you can note how far the tube is in or out (tubes have centimeter marking lines).