There was an enormous outcry against the forced placement of temporary feeding tubes in the noses of prisoners on hunger strikes in Guantánamo. Dramatic and inaccurate representations of the tubes as torture appeared on the internet. We ethicists wrung our hands and worried as much about the rights of the prisoners as we did about the false message that was being delivered: that nasal feeding tubes are torture. But another kind of forced feeding, this one using unnecessary surgery, goes on unchallenged every day here in the United States. In some regions, this practice is simply an option, but in others it is adhered to with a nearly religious fervor.
In biomedical ethics, no single concept is more important than patient autonomy: the ability to determine what happens to one’s body. Moreover, we clinicians all commit to doing no harm. While clearly motivated by fear of harm from the nasal tubes, misguided nursing home policies — rather than medical indications — are driving practice. Because of the rigidity of these policies in the effected regions, tube-fed patients needing nursing-home care cannot be discharged from the hospital unless the surgical tube is placed. The patients, their families and those caring for them in hospitals face a distressing moral dilemma: force an unnecessary surgery on the patient or face not being able to discharge them from the hospital.
This practice is driving changes in care throughout hospitalization. The medical literature is full of reports of patients undergoing the insertion of the surgical tube while critically ill in an intensive care unit to avoid prolonging the hospital stay, since it is anticipated that the patient will need to be discharged to a nursing home unable to eat at some point in the future. In published reports, including ours, somewhere around 10 percent of patients who have the surgical tube inserted do not survive to discharge. In one study from Penn State University and Johns Hopkins University, most of the surgical tubes had been removed before the surviving patients were even discharged from the hospital. The mortalities are not due to complications of the procedure. But the high death rate and removal before discharge underscore that there are pressures to insert too many of these tubes.
In fairness, the medical directors of several of the nursing homes in our network have agreed to work toward improving the skills of their nursing staff such that they can accept the nasal tubes. But they lack funding for the training, and are unable to prioritize making these changes.
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