Enteral Feeding for Patients with Dementia – An ethical critique of the clinical and economic considerations

Clovis Mariano Faggion Junior is a dental surgeon working at the University of Münster, Germany, and is involved in secondary research, including systematic reviews and meta-research, with a focus on evidence-based medicine and ethical questions.

Enteral nutrition is defined as “the delivery of a nutritionally complete feed directly into the gut via a tube.”¹ While this method has well-established benefits in various medical conditions,² its use in advanced dementia, including Alzheimer’s disease, remains controversial due to limited evidence supporting its efficacy and the ethical concerns it raises.

The use of enteral feeding in late-stage dementia has been examined in the literature.^3,4 Current guidelines advise against its routine use as a standard treatment and care practice for dementia patients. Instead, enteral feeding should only be considered when a patient has explicitly provided informed consent for artificial nutrition. In cases where consent is unavailable, decisions should be made through careful discussions with family members and designated decision-makers, balancing potential benefits and risks. The decision to offer or not offer enteral feeding for patients with dementia may be complicated by clinical, ethical and economic factors.

Clinical Evidence on the Effectiveness of Enteral Feeding

A 2021 Cochrane review concluded that “there is no evidence that tube feeding improves survival, quality of life, or nourishment, nor does it reduce pain, mortality, behavioral symptoms of dementia, or caregiver burden.”⁵ At the same time, other evidence suggests that tube feeding may prolong survival in Alzheimer’s patients.⁶ This discrepancy raises questions about whether specific factors, such as the type of nutrition provided or the overall quality of care in facilities using enteral feeding, contribute to better survival outcomes. For instance, nursing homes that provide nutritionally fortified liquid meals and implement strict infection-control protocols may report improved survival rates.

Are there any risks associated with enteral feeding in patients with dementia?

A Cochrane systematic review⁵ identified a potential increase in the risk of pressure ulcers linked to enteral feeding. Additionally, enteral tube feeding may lead to a greater risk of pneumonia in patients with dementia. Another important consideration is the potential harm caused when enteral feeding tubes need to be replaced, which can be particularly distressing for dementia patients.

Comfort Feeding vs. Enteral Feeding

One justification for tube feeding in Alzheimer’s patients is the development of swallowing difficulties, making enteral nutrition a potential last resort for sustaining life. However, an alternative approach, comfort- (also sometimes referred to as as risk-) feeding, can often be considered.⁷ This method may involve modifying food textures to softer solids and thickened liquids, as well as taking time and care to assist with feeding, to facilitate safer oral intake. Comfort-feeding prioritizes the patient’s quality of life, but it requires a well-trained nursing staff capable of managing the challenges associated with feeding individuals with advanced dementia. Nursing home culture may influence the use of enteral feeding in patients with advanced cognitive impairment. Facilities that prioritize quality of life—emphasizing the enjoyment of food, maintaining a well-structured environment with well-trained staff, and involving family members in shared decision-making—generally have lower rates of feeding tube use compared to those without these characteristics.⁸ A question that may be raised here is: Are nursing homes that prioritize logistics and potential profit over the quality of life of dementia patients following an ethical pathway that considers multiple factors such as clinical indications, patient preferences, and quality of life as well as broader issues of economic possibility and justice?⁹

Who Benefits from Enteral Feeding in Dementia Patients?

Although guidelines advise against its routine use in nursing homes, the reasons for its persistent implementation should be clarified. One possible explanation is that enteral feeding offers logistical advantages for care facilities. Manually feeding patients with advanced dementia can be time-consuming due to cognitive and communication challenges. In contrast, tube feeding simplifies the process by delivering nutrients directly, allowing nursing staff to allocate time to other patients. Additionally, patients with advanced dementia may receive regular medication to manage behavioral symptoms, which can further reduce the caregiving burden.

A strong potential conflict of interest may arise when enteral feeding for dementia patients is embedded in a nursing home with an environment that favors extended tube feeding and a higher likelihood of survival. In such an environment, where patients with dementia have a low risk of infection, receive fortified nutrition through enteral feeding, and are treated with next-generation antibiotics in case of infection, the nursing home may create a highly cost-effective scenario, potentially extending care over longer periods of time.

Beyond logistical considerations, financial incentives may also play a role. The use of enteral feeding requires specialized equipment, such as feeding tubes and pumping machines, which generates demand for medical supplies and services. This economic factor could contribute to the persistence of enteral feeding in settings where alternative feeding methods may be more appropriate.

Some evidence suggests that enteral feeding constitutes a significant portion of the costs associated with hospitalized patients, particularly those with cancer or dementia.¹⁰ A systematic review¹¹ assessed the total costs and cost-effectiveness of home enteral nutrition. The authors concluded that, from a cost-effectiveness perspective, enteral feeding is unlikely to be beneficial for patients with dementia.

Ethical Considerations in Enteral Feeding for Dementia Patients

A key aspect of the decision to implement enteral feeding in dementia patients is transparency in communication between all involved parties—physicians, family members, and, the patient’s designated decision-maker. Clear and open discussions are essential to ensure that medical interventions align with the patient’s best interests and ethical standards.

One commonly cited justification for enteral feeding in dementia patients is the presence of severe dysphagia, which may increase the risk of malnutrition and aspiration pneumonia. However, two critical questions should be addressed before proceeding with this intervention: 1) has a formal diagnosis of severe dysphagia been established?; 2) If so, have physicians and caregivers made comprehensive efforts to implement more conservative approaches, such as comfort feeding, before resorting to tube feeding?

During the deliberation on decisions regarding life-sustaining treatments, physicians have a responsibility to clearly outline the potential benefits, risks, and limitations of enteral feeding, along with alternative care options. While some argue that enteral feeding is implemented in the best interest of patients, others raise concerns about the broader systemic and financial influences that may sustain its use. The economic incentives associated with enteral nutrition warrant further scrutiny. If multiple stakeholders benefit from enteral feeding while the patient’s quality of life remains uncertain, ethical concerns must be addressed.

Broader professional and societal discussions are needed to evaluate the implications of enteral feeding in advanced dementia care. Healthcare professionals must remain committed to prioritizing patient well-being, ensuring that clinical decisions are based on medical necessity rather than external pressures. Ultimately, it is essential to question whether the pursuit of life prolongation in such cases aligns with dignity, ethical care, and the patient’s best interests.

References

1. NICE Guidelines.Enteral (tube) feeding for people living with severe dementia. https://www.nice.org.uk/guidance/ng97/resources/enteral-tube-feeding-for-people-living-with-severe-dementia-patient-decision-aid-pdf-4852697007. Accessed on 01 March 2025
2. Bechtold ML, Brown PM, Escuro A, et al. When is enteral nutrition indicated? Journal of Parenteral and Enteral Nutrition. 2022;46(7):1470-1496. doi:10.1002/jpen.2364
3. Zaza SI, Jacobson N, Buffington A, et al. Systems Forces Leading to Feeding Tube Placement in Patients with Advanced Dementia: A Qualitative Exploration of Clinical Momentum. J Palliat Med. 2024;27(8):993-1000. doi:10.1089/jpm.2023.0555
4. Avnon Sawicki A, Dwolatzky T, Clarfield AM. Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy. Eur Geriatr Med. 2023;14(1):219-222. doi:10.1007/s41999-022-00725-2
5. Davies N, Barrado-Martín Y, Vickerstaff V, et al. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev. 2021;8(8):CD013503. doi:10.1002/14651858.CD013503.pub2
6. Takayama K, Hirayama K, Hirao A, et al. Survival times with and without tube feeding in patients with dementia or psychiatric diseases in Japan. Psychogeriatrics. 2017;17(6):453-459. doi:10.1111/psyg.12274
7. Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010;58(3):580-584. doi:10.1111/j.1532-5415.2010.02740.x
8. Lopez RP, Amella EJ, Strumpf NE, Teno JM, Mitchell SL. The influence of nursing home culture on the use of feeding tubes. Arch Intern Med. 2010;170(1):83-88. doi:10.1001/archinternmed.2009.467
9. Sokol DK. The “four quadrants” approach to clinical ethics case analysis; an application and review. J Med Ethics. 2008 Jul;34(7):513-6. doi: 10.1136/jme.2007.021212. PMID: 18591284.
10. Hyeda A, da Costa ÉSM. Economic analysis of costs with enteral and parenteral nutritional therapy according to disease and outcome. Einstein (Sao Paulo). 2017;15(2):192-199. doi:10.1590/S1679-45082017GS4002
11. Wong A, Goh G, Banks MD, Bauer JD. A systematic review of the cost and economic outcomes of home enteral nutrition. Clin Nutr. 2018;37(2):429-442. doi:10.1016/j.clnu.2017.06.019

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