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Der Nervenarzt

, Volume 78, Issue 4, pp 418–428 | Cite as

PEG-Ernährung bei fortgeschrittener Demenz

Eine evidenzgestützte ethische Analyse
  • M. SynofzikEmail author
Originalien

Zusammenfassung

Entscheidungen über eine Sondenernährung bei Patienten mit fortgeschrittener Demenz gestalten sich aufgrund der unklaren empirischen Evidenz und komplexen ethischen Verpflichtungen in der klinischen Praxis oftmals schwierig. Im Folgenden werden ethische Kriterien und empirische Evidenz erstmals systematisch zusammengeführt. Diese Analyse unter den Kriterien des Wohlergehens, des Nichtschadens und der Autonomie zeigt, dass bei vielen Patienten mit fortgeschrittener Demenz auf eine Sondenernährung verzichtet werden sollte: Neuere empirische Studien demonstrieren, (1) dass es keinen Nachweis eines Nutzens gibt, (2) dass eine PEG-Ernährung einem Demenzpatienten oftmals weiteren Schaden zufügt und (3) dass der erklärte bzw. mutmaßliche Patientenwille zumeist nicht ausreichend beachtet wird. Ein praxisorientiertes Modell zur interdisziplinären Entscheidungsfindung wird diesen verschiedenen Schwierigkeiten gerecht und könnte die empirisch und ethisch anspruchsvolle Entscheidungsfindung zur PEG-Ernährung bei fortgeschrittener Demenz wesentlich erleichtern.

Schlüsselwörter

Therapieverzicht Demenz Künstliche Ernährung Gastrostomie Entscheidungsfindung Leitlinien Ethik 

Tube-feeding in advanced dementia

An evidence-based ethical analysis

Summary

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient’s will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.

Keywords

Withholding treatment Algorithms Artificial nutrition Decision making Dementia Ethics Gastrostomy 

Notes

Interessenkonflikt

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Literatur

  1. 1.
    Abuksis G, Mor M, Segal N et al. (2000) Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients. Am J Gastroenterol 95: 128−132CrossRefPubMedGoogle Scholar
  2. 2.
    Ahronheim JC, Gasner MR (1990) The sloganism of starvation. Lancet 335: 278−279CrossRefPubMedGoogle Scholar
  3. 3.
    Alvarez-Fernandez B, Garcia-Ordonez MA et al. (2005) Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality. Int J Geriatr Psychiatry 20: 363−370CrossRefPubMedGoogle Scholar
  4. 4.
    Beauchamp T, Childress J (2001) Principles of Biomedical Ethics, 5th edn. Oxford Univ Press, New York OxfordGoogle Scholar
  5. 5.
    Bernat JL, Beresford HR (2006) The controversy over artificial hydration and nutrition. Neurology 66: 1618−1619CrossRefPubMedGoogle Scholar
  6. 6.
    Bourdel-Marchasson I, Barateau M et al. (2000) A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d’Evaluation. Nutrition 16: 1−5CrossRefPubMedGoogle Scholar
  7. 7.
    Brotherton A, Abbott J, Aggett P (2006) The impact of percutaneous endoscopic gastrostomy feeding upon daily life in adults. J Hum Nutr Diet 19: 355−367CrossRefPubMedGoogle Scholar
  8. 8.
    Buijssen H (1994) Senile Demenz: eine praktische Anleitung für den Umgang mit Alzheimer-Patienten. Beltz, WeinheimGoogle Scholar
  9. 9.
    Callahan CM, Haag KM, Buchanan NN, Nisi R (1999) Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc 47: 1105−1109PubMedGoogle Scholar
  10. 10.
    Callahan CM, Haag KM, Weinberger M et al. (2000) Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc 48: 1048−1054PubMedGoogle Scholar
  11. 11.
    Carver AC, Vickrey BG, Bernat JL et al. (1999) End-of-life care: a survey of US neurologists‘ attitudes, behavior, and knowledge. Neurology 53: 284−293PubMedGoogle Scholar
  12. 12.
    Cefalu CA (1999) Appropriate dysphagia evaluation and management of the nursing home patient with dementia. Ann Long Term Care 7: 447−451Google Scholar
  13. 13.
    Chernoff R (2006) Tube feeding patients with dementia. Nutr Clin Pract 21: 142−146PubMedGoogle Scholar
  14. 14.
    Ciment J (2000) Tube feeding bad for patients with dementia. BMJ 320: 335BCrossRefPubMedGoogle Scholar
  15. 15.
    Deutscher Juristentag (2006) Strafrecht: Patientenautonomie und Strafrecht bei der Sterbebegleitung. In: 66. Deutscher Juristentag 2006, Stuttgart, http://www.djt.de/index.php.
  16. 16.
    Dharmarajan TS, Unnikrishnan D, Pitchumoni CS (2001) Percutaneous endoscopic gastrostomy and outcome in dementia. Am J Gastroenterol 96: 2556−2563CrossRefPubMedGoogle Scholar
  17. 17.
    Fagerlin A, Schneider CE (2004) Enough. The failure of the living will. Hastings Cent Rep 34: 30−42PubMedGoogle Scholar
  18. 18.
    Feinberg MJ, Knebl J, Tully J (1996) Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia 11: 104−109CrossRefPubMedGoogle Scholar
  19. 19.
    Ferrell BA, Josephson K, Norvid P, Alcorn H (2000) Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 48: 1042−1047PubMedGoogle Scholar
  20. 20.
    Finucane TE (1995) Malnutrition, tube feeding and pressure sores: data are incomplete. J Am Geriatr Soc 43: 447−451PubMedGoogle Scholar
  21. 21.
    Finucane TE, Bynum JP (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 348: 1421−1424CrossRefPubMedGoogle Scholar
  22. 22.
    Finucane TE, Christmas C, Travis K (1999) Tube feeding in patients with advanced dementia: a review of the evidence. Jama 282: 1365−1370CrossRefPubMedGoogle Scholar
  23. 23.
    Finucane TE (2004) Malnutrition and pressure ulcers: data are still incomplete. J Am Geriatr Soc 52: 163; author reply 163−164CrossRefPubMedGoogle Scholar
  24. 24.
    Ganzini L, Goy ER, Miller LL et al. (2003) Nurses‘ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med 349: 359−365CrossRefPubMedGoogle Scholar
  25. 25.
    Ganzini L (2006) Artificial nutrition and hydration at the end of life: ethics and evidence. Palliat Support Care 4: 135−143PubMedGoogle Scholar
  26. 26.
    Gillick MR (2000) Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 342: 206−210CrossRefPubMedGoogle Scholar
  27. 27.
    Gossner L, Ludwig J, Hahn EG, Ell C (1995) Risiken der perkutanen endoskopischen Gastronomie. Dtsch Med Wochenschr 120: 1768−1772PubMedGoogle Scholar
  28. 28.
    Harper J, McMurdo ME, Robinson A (1999) Outcomes of percutaneous endoscopic gastrostomy feeding. Age Ageing 28: 497−498CrossRefGoogle Scholar
  29. 29.
    Hasan M, Meara RJ, Bhowmick BK, Woodhouse K (1995) Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals. Gerontology 41: 326−331PubMedGoogle Scholar
  30. 30.
    Karlawish JH, Casarett D, Klocinski J, Clark CM (2001) The relationship between caregivers‘ global ratings of Alzheimer’s disease patients‘ quality of life, disease severity, and the caregiving experience. J Am Geriatr Soc 49: 1066−1070CrossRefPubMedGoogle Scholar
  31. 31.
    Kaw M, Sekas G (1994) Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients. Dig Dis Sci 39: 738−743CrossRefPubMedGoogle Scholar
  32. 32.
    Kreß H (2004) Selbstbestimmung am Lebensende. Die Bioethik-Kommission Rheinland-Pfalz zur Sterbehilfe und Sterbebegleitung. Zeitschrift für Ethik in der Medizin 16: 291−297CrossRefGoogle Scholar
  33. 33.
    Kruse A (2005) Lebensqualität demenzkranker Menschen. Zeitschrift für Medizinische Ethik 51: 41−57Google Scholar
  34. 34.
    Lacey D (2004) Tube feeding in advanced Alzheimer’s disease: when language misleads. Am J Alzheimers Dis Other Demen 19: 125−127CrossRefPubMedGoogle Scholar
  35. 35.
    Marckmann G (2000) Was ist eigentlich prinzipienorientierte Medizinethik? Ärzteblatt Baden-Württemberg 55: 499−502Google Scholar
  36. 36.
    Marckmann G (2004) Lebensverlängerung um jeden Preis? Ärzteblt Bad-Württ 59: 379−382Google Scholar
  37. 37.
    Marckmann G (2005) Prinzipienorientierte Medizinethik im Praxistest. In: Rauprich O, Steger F (eds) Prinzipienethik in der Biomedizin. Moralphilosophie und medizinische Praxis. Campus, Frankfurt New York, pp 398−415.Google Scholar
  38. 38.
    McCann RM, Hall WJ, Groth-Juncker A (1994) Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. Jama 272: 1263−1266CrossRefPubMedGoogle Scholar
  39. 39.
    McCann R (1999) Lack of evidence about tube feeding − food for thought. Jama 282: 1380−1381CrossRefPubMedGoogle Scholar
  40. 40.
    McNabney MK, Beers MH, Siebens H (1994) Surrogate decision-makers‘ satisfaction with the placement of feeding tubes in elderly patients. J Am Geriatr Soc 42: 161−168.PubMedGoogle Scholar
  41. 41.
    Meier DE, Ahronheim JC, Morris J et al. (2001) High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Arch Intern Med 161: 594−599CrossRefPubMedGoogle Scholar
  42. 42.
    Mitchell SL, Kiely DK, Lipsitz LA (1997) The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 157: 327−332CrossRefPubMedGoogle Scholar
  43. 43.
    Mitchell SL, Lawson FM (1999) Decision-making for long-term tube-feeding in cognitively impaired elderly people. Cmaj 160: 1705−1709PubMedGoogle Scholar
  44. 44.
    Mitchell SL, Berkowitz RE, Lawson FM, Lipsitz LA (2000) A cross-national survey of tube-feeding decisions in cognitively impaired older persons. J Am Geriatr Soc 48: 391−397.PubMedGoogle Scholar
  45. 45.
    Mitchell SL, Kiely DK, Gillick MR (2003) Nursing home characteristics associated with tube feeding in advanced cognitive impairment. J Am Geriatr Soc 51: 75−79CrossRefPubMedGoogle Scholar
  46. 46.
    Monteleoni C, Clark E (2004) Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ 329: 491−494CrossRefPubMedGoogle Scholar
  47. 47.
    Murphy LM, Lipman TO (2003) Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med 163: 1351−1353CrossRefPubMedGoogle Scholar
  48. 48.
    Nair S, Hertan H, Pitchumoni CS (2000) Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Am J Gastroenterol 95: 133−136CrossRefPubMedGoogle Scholar
  49. 49.
    Niv Y, Abuksis G (2002) Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects. Dig Dis 20: 253−256CrossRefPubMedGoogle Scholar
  50. 50.
    Park RH, Allison MC, Lang J et al. (1992) Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. Bmj 304: 1406−1409PubMedGoogle Scholar
  51. 51.
    Pasman HR, The BA, Onwuteaka-Philipsen BD et al. (2003) Feeding nursing home patients with severe dementia: a qualitative study. J Adv Nurs 42: 304−311CrossRefPubMedGoogle Scholar
  52. 52.
    Pasman HR, Onwuteaka-Philipsen BD, Kriegsman DM et al. (2005) Discomfort in nursing home patients with severe dementia in whom artificial nutrition and hydration is forgone. Arch Intern Med 165: 1729−1735CrossRefPubMedGoogle Scholar
  53. 53.
    Peck A, Cohen CE, Mulvihill MN (1990) Long-term enteral feeding of aged demented nursing home patients. J Am Geriatr Soc 38: 1195−1198PubMedGoogle Scholar
  54. 54.
    Phillips PA, Rolls BJ, Ledingham JG et al. (1984) Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 311: 753−759PubMedGoogle Scholar
  55. 55.
    Pick N, McDonald A, Bennett N et al. (1996) Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors. J Am Geriatr Soc 44: 763−768.PubMedGoogle Scholar
  56. 56.
    Post S (2000) The Moral Challenge of Alzheimer Disease: Ethical Issues from Diagnosis to Dying. John Hopkins Uni Press, BaltimoreGoogle Scholar
  57. 57.
    Post SG (2001) Tube feeding and advanced progressive dementia. Hastings Cent Rep 31: 36−42Google Scholar
  58. 58.
    Printz LA (1992) Terminal dehydration, a compassionate treatment. Arch Intern Med 152: 697−700CrossRefPubMedGoogle Scholar
  59. 59.
    Quill TE (1989) Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital. Arch Intern Med 149: 1937−1941CrossRefPubMedGoogle Scholar
  60. 60.
    Rabeneck L, Wray NP, Petersen NJ (1996) Long-term outcoes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med 11: 287−293PubMedGoogle Scholar
  61. 61.
    Rabeneck L, McCullough LB, Wray NP (1997) Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 349: 496−498CrossRefPubMedGoogle Scholar
  62. 62.
    Ready RE, Ott BR, Grace J (2004) Patient versus informant perspectives of Quality of Life in Mild Cognitive Impairment and Alzheimer’s disease. Int J Geriatr Psychiatry 19: 256−265.CrossRefPubMedGoogle Scholar
  63. 63.
    Rothärmel S (2004) Juristischer Kommentar. Z Ethik Med 16: 289−290CrossRefGoogle Scholar
  64. 64.
    Sachs GA (1998) Dementia and the goals of care. J Am Geriatr Soc 46: 782−783PubMedGoogle Scholar
  65. 65.
    Sanders DS, Carter MJ, D’Silva J et al. (2000) Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol 95: 1472−1475CrossRefPubMedGoogle Scholar
  66. 66.
    Sanders DS, Anderson AJ, Bardhan KD (2004) Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia. Clin Med 4: 235−241PubMedGoogle Scholar
  67. 67.
    Scott AG, Austin HE (1994) Nasogastric feeding in the management of severe dysphagia in motor neurone disease. Palliat Med 8: 45−49PubMedGoogle Scholar
  68. 68.
    Shega JW, Hougham GW, Stocking CB et al. (2003) Barriers to limiting the practice of feeding tube placement in advanced dementia. J Palliat Med 6: 885−893CrossRefPubMedGoogle Scholar
  69. 69.
    Sheiman SL (1996) Tube feeding the demented nursing home resident. J Am Geriatr Soc 44: 1268−1270PubMedGoogle Scholar
  70. 70.
    Simon A (2004) Ethische Aspekte der künstlichen Ernährung bei nichteinwilligungsfähigen Patienten. Z Ethik Med 16: 217−228CrossRefGoogle Scholar
  71. 71.
    Solomon MZ, O’Donnell L, Jennings B et al. (1993) Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health 83: 14−23PubMedGoogle Scholar
  72. 72.
    Steinbrook R, Lo B (1988) Artificial feeding - solid ground, not a slippery slope. N Engl J Med 318: 286−290PubMedGoogle Scholar
  73. 73.
    Strätling M, Schmucker P, Bartmann F-J (2005) Künstliche Ernährung: Gut gmeint ist nicht immer gut gemacht. Deutsches Ärzteblatt 102: A 2153−2154Google Scholar
  74. 74.
    Sullivan RJ Jr (1993) Accepting death without artificial nutrition or hydration. J Gen Intern Med 8: 220−224PubMedGoogle Scholar
  75. 75.
    Sullivan-Marx EM, Strumpf NE, Evans LK et al. (1999) Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts. J Am Geriatr Soc 47: 342−348PubMedGoogle Scholar
  76. 76.
    Synofzik M, Marckmann G (2005) Persistent Vegetative State: Verhungern lassen oder sterben dürfen? Deutsches Ärzteblatt 102: A 2079−2082Google Scholar
  77. 77.
    Synofzik M (2006) Kognition a la carte? Der Wunsch nach kognitionsverbessernden Psychopharmaka in der Medizin. Zeitschrift für Ethik in der Medizin 18: 37−50CrossRefGoogle Scholar
  78. 78.
    Synofzik M (2006) Wirksam, indiziert − und dennoch ohne Nutzen? Die Ziele der medikamentösen Demenz-Behandlung und das Wohlergehen des Patienten. Z Gerontol Geriatr 39: 301−307CrossRefPubMedGoogle Scholar
  79. 79.
    Taupitz J (2000) Die Situation des nicht äußerungsfähigen Patienten ohne (erreichbaren) Vertreter. In: Verhandlungen des 63. Juristentages Leipzig 2000, pp A36−51. Mücnhen: C.H. BeckGoogle Scholar
  80. 80.
    Van Rosendaal GM, Verhoef MJ, Kinsella TD (1999) How are decisions made about the use of percutaneous endoscopic gastrostomy for long-term nutritional support? Am J Gastroenterol 94: 3225−3228PubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2007

Authors and Affiliations

  1. 1.Institut für Ethik und Geschichte in der MedizinUniversität TübingenTübingen Deutschland
  2. 2.Abteilung für Kognitive NeurologieHertie Institut für Klinische HirnforschungTübingenDeutschland

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