Definitions: “Artificial Nutrition/Hydration”
April 1, 2012 Leave a comment
The terms that refer to the infusion of nutritive or hydrating substances are particularly thorny. Sometimes, providers refer to the technique as providing artificial nutrition or hydration; in other instances, they discuss the option of a feeding tube” which is euphemistic at best, and deceptive at worst.
I don’t mean to imply here that doctors are actively hoping to deceive their patients into using (or foregoing) certain medical treatments. A doctor who convinces Mrs. N to administer artificial nutrition to her husband may have the incentive of keeping him alive so the doctor can continue to receive payment for his services. But if Mrs. N’s husband does not receive artificial nutrition, and is instead allowed a natural life and death at home, the doctor can (equally crudely put) quickly fill Mr. N’s empty bed with a new patient, just as needy for care but less expensive to the hospital. These are both particularly negative ways of viewing this conversation; the point is that doctors rarely have a compelling self-interest in changing terminology to convince patients to do one thing or another.
Instead, the goal of the term “artificial nutrition/hydration” is to simplify a rather complex and unpleasant procedure. Let’s start with feeding tubes. What does that phrase bring to mind? Perhaps a nurse explained to Mrs. N that Mr. N is unable to swallow solid foods on his own; but with a feeding tube, he will receive adequate nutrition. Mrs. N, a competent woman, draws an connection between her husband’s circumstance and an infant’s analogous inability to manage solid foods. Mrs. N knows that, with a baby, she takes care of the problem by emulsifying, or even liquifying, the infant’s food to make it easier to eat. Mrs. N doesn’t want to bother the busy doctor with her clever analogy, so she simply agrees to the procedure.
Several days later, when Mrs. N returns, her husband has a snakelike, rubber arm protruding from his abdomen. She is distraught at this surgery that occurred without her knowledge, and demands that the doctor explain why there is a tube in her husband’s stomach. The doctor answers, “That’s the G-tube you asked for!” As Mrs. N sputters that she did no such thing, she did not authorize any surgery or invasive pipes, she agreed to a feeding tube. Here, the doctor realizes the error. He kindly explains that “feeding tube” is a simplified way of referencing this procedure; since Mrs. N did not express any confusion, he presumed that she agreed with his decision.
A more explicit clarification of a “feeding tube” sounds more like this. As Mr. N’s condition deteriorates, he may slowly lose muscle agility, tone, and control. Because eating and drinking involve great and specific coordination between mouth (oral), throat (esophageal), and other muscles, these tasks often need to be altered and simplified. There are several ways of achieving this, with varying degrees of departure from “normal” eating:
- Purée — Mr. N finds his removable dentures uncomfortable to wear during meals, and because his body and digestive system are under stress from his age and illness, his nurses purée his meals before serving. That way, he can easily “chew” his food without worrying about pain; further, if he is experiencing digestive problems, puréeing his food acts as a pre-emulsifier, accomplishing the job of some stomach acids. Many hospitals and homes have taken to puréeing each dish (main course; side dish; etc) separately and using molds to try to recreate what the dish originally looked like, in an effort to normalize the meal and make it as appetizing as possible.
- Thickened liquids — as Mr. N finds it more difficult to direct liquids to his esophagus and stomach, rather than his trachea and lungs, (sometimes from stroke-induced dysphagia, a difficulty with swallowing) his nurse worries about his risk of aspiration, or breathing in liquids. In response, she adds flavorless thickening agents to his drinks, so that they have a consistency less like water and more like chocolate milk or a smoothie. Still clearly a drink, but much less dangerous.
- Gastrointestinal tube (enteral nutrition) — There are a number of factors that might lead to using a G tube (sometimes called a GItube or J tube). (This is the administration route to which Mrs. N agreed.) 1) Mr. N simply refuses to eat because he cannot stand puréed food. 2) Mr. N’s dysphagia is so severe that it would be dangerous to serve him even puréed food and thickened liquids. 3) Mr. N has sores or other sources of discomfort in his mouth and throat, and so eating is painful for him. Etc. Whatever the reason, a G tube provides necessary nutrition through an abdominal incision, bypassing traditional eating mechanisms, and delivers them directly to the stomach or intestines, where they are absorbed.
- Intravenous nutrition (parenteral nutrition) — IV administration routes are used when there is severe enough damage or disability in Mr. N’s digestive tract that the most effective way of providing nutrients is through the veins or other non-intestinal methods.
Once her husband’s doctor explained these differences to Mrs. N, she was better able to understand why “feeding tube” was so misleading. Because of the terminology used, Mrs. N imagined that a nurse would feed her husband puréed meals with the help of a tube. Instead, she was shocked to learn that he would not taste anything with a “feeding” tube. However, despite his oral discomfort, he could still obtain the necessary nutrients as long as necessary.