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Appendix

Technical Aspects Of Medically Assisted Nutrition And Hydration

Procedures for providing nourishment and fluids to patients who cannot swallow food orally are either "parenteral" (bypassing the digestive tract) or "enteral" (using the digestive tract).

Parenteral or intravenous feeding is generally considered "more hazardous and more expensive" than enteral feeding.[42] It can be subdivided into peripheral intravenous feeding (using a needle inserted inro a peripheral vein) and central intravenous feeding, also known as total parenteral feeding or hyperalimentation (using a larger needle inserted into a central vein near the heart). Peripheral intravenous lines can provide fluids and electrolytes as well as some nutrients; they can maintain fluid balance and prevent dehydration, but cannot provide adequate nutrition in the long term. [43] Total parenteral feeding can provide a more adequate nutritional balance, but poses significant risks to the patient and may involve costs an order of magnirude higher than other methods of tube feeding. It is no longer considered experimental and has become "a mainstay for helping critically ill patients to survive acute illnesses where the prognosis had previously been nearly hopeless," but its feasibility for life-long maintenance of patients without a functioning gastrointestinal tract has been questioned.[44]

Because of the limited usefulness of peripheral intravenous feeding and the special burdens of total parenteral feeding—and because few patienrs so completely lack a digestive system that they must depend on these measures for their sole source of nutrition - enteral tube feeding is the focus of the current debate over medically assisted nutrition and hydration. Such methods are used when a patient has a functioning digestive system but is unable or unwilling to ingest food orally and/or to swallow. The most common routes for enteral tube feeding are nasogastric (introducing a thin plastic tube through the nasal cavity to reach into the stomach), gastrostomy (surgical insertion of a tube through the abdominal wail into the stomach), and jejunostomy (surgical insertion of a tube through the abdominal wall into the small intestine).[45] These methods are the primary focus of this document.

Each method of enteral tube feeding has potential side effects. For example, nasogastric tubes must be inserted and monitored carefully so that they will not introduce food or fluids into the lungs. They may also irritate sensitive tissues and create discomfort; confused or angry patients may sometimes try to remove them; and efforts to restrain a patient to prevent this can impose additional discomfort and other burdens. On the positive side, insertion of these tubes requires no surgery and only a modicum of training.[46]

Gastrostomy and jejunostomy tubes are better tolerated by many patients in need of long-term feeding. Their most serious physical burdens arise from the fact that their insertion requires surgery using local or general anesthesia, which involves some risk of infection and other complications. Once the surgical procedure is completed, these tubes can often be maintained without serious pain or medical complications, and confused patients do not often attempt to remove them.[47]