La valutazione degli outcomes e le implicazioni etiche e gestionali nella nutrizione enterale The analysis of clinical outcomes and the ethical aspects in tube feeding decision

Objective: Deciding whether to iniziate artificial enteral nutrition (EN) in pa- tients with severe cognitive impairment or with permanent vegetative state is a common dilemma. The decision is based not only an clinical grounds but also on ethical aspects. Recent studies have not demonstrated that tube feeding can improve important outcomes; many authors discourage this practice in severe- ly demented patients. The aims of this study are to control if the nutrition sup- port team management of enterally fed patients improves outcomes and to pre- sent a flow-chart comprehensive of biological and ethical aspects. Methods: This is one of the few studies in literature describing the use of EN in an area where all candidates are assessed by a nutrition support team: 8 patients were in Hospital, 39 patients in nursing homes and 61 patients at home. We have included 108 patients, mean age 78.2 years, 38 males and 70 females. We have followed the guidelines of the Italian Society of Parenteral and Enteral Nutrition (SINPE) for the clinical indication of EN. The quarterly follow-up has been pro- longed up to 14 years. The following parameters were analyzed: diagnoses, nu- tritional indices, pressure scores, complications, mortality, ADL e IADL scales, Norton scale, Pfeiffer test, Karnofsky index. Results: Demented patients were 82.4% of the cohort. The first month mortality rate was 7.4% and 23.1% at one year. The mean survival was 674 days. The main compli- cations of NGT versus PEG have been aspiration 15.5% and 7.9%, tube dislodgment 62.2% and 4.7%, and tube clodging 11.1% and 7.9%, respectively. EN was delivered by PEG in 62 patients, NGT in 45 patients and jejunostomy in one patient. Conclusion: In our study the mortality rate was nearly half of rates reported in literature and the survival approaches two years. Almost all complications have been mild and could be managed adequately throughout; their prevalence is low if confronted to the long period of follow- up, for a whole of 73.953 days. This positive outcome may be the result of the se- lection and follow-up program supervised by the nutrition support team. How should we treat psycogeriatric patients who no longer eat? We believe that the answer to this complex dilemma should consider not only biological but al- so ethical aspects and should offer to the patient an alternative treatment to en- teral nutrition.