Plaintiff Complaint: “Plaintiff Joe Smith suffered a severe and debilitating pressure injury, caused by severe malnutrition and weight loss. This could have been avoided had defendant facility initiated tube feeding to supply plaintiff with sufficient calories and nutrition to prevent weight loss.”

National Pressure Injury Advisory Panel (NPIAP) Guidelines 2019: “Discuss the benefits and harms of enteral or parenteral feeding to support overall health in light of preferences and goals of care with individuals at risk of pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions.”¹

Introduction

As detailed in my last few blogs, nutrition plays a huge role in risk for skin breakdown as well as healing of wounds. Just about ALL wound litigation involves nutrition in one way or another, be it diabetes control (or lack thereof) or weight loss, which occurs often in patients with dementia and toward end of life, or general malnutrition.

The Anorexia of Aging

Many individuals experience unintentional weight loss at older ages, a condition often called the “anorexia of aging.” This is defined as a decrease in appetite and/or food intake in old age.² It often is the result of physiologic and hormonal changes such as ghrelin and leptin as we age, gastrointestinal motility changes, medications, inflammation, or other issues such as depression, poor dentition, poor cognition, decrease in smell or taste, and many other factors. Some older adult patients develop a condition called presbyesophagus, an abnormal shape of the esophagus, or esophageal dysmotilities that contribute to feeding and swallowing difficulties leading to dysphagia and potential aspiration pneumonia. It can be very distressing for family to witness what can be extreme, unintentional weight loss.

Feeding Tubes

One option is insertion of a feeding tube for enteral nutrition, but is that always a good idea, and does it lead to decreased weight loss and improved pressure injury outcomes? The American Geriatrics Society and many nutrition experts say "NO, not necessarily". Various studies have failed to show that the use of feeding tubes is effective in preventing malnutrition, improving pressure injury outcomes, preventing aspiration pneumonia, providing comfort, improving functional status, or extending life.³

If anything, feeding tubes are associated with substantial increased health burden, including recurrent and new-onset aspiration, tube-associated and aspiration-related infections, oral secretions that are difficult to manage, discomfort, tube malfunction, use of physical and chemical restraints, and increased pressure injury incidence. The head of the bed must be up to prevent aspiration, and this position causes more shear forces. There is increased diarrhea, leading to an increased risk of skin breakdown.

So, What to Do?

The NPIAP provides some guidance in their guideline by stating that clinicians should discuss the “benefits and harm in light of preferences and goals of care.” This speaks to two things: the importance of advanced directives and discussions, preferably before the onset of dementia or disabling illness; and how tremendously important it is to be communicative and open with family members and caregivers. Often, lawsuits are precipitated by poor communication. Proper communication is the key to managing the often unrealistic expectations of patients and families.⁴

The American Geriatrics Society states that feeding tubes are NOT recommended for patients with dementia, and that hand feeding should be offered. Hand feeding has been shown to be as good as tube feeding without a lot of its drawbacks. Unfortunately, in the time of COVID-19 there have been unprecedented staffing shortages, thus making it difficult at times for staff to provide the extra care. Sometimes, tube feeding is suggested more because of medicolegal risk and to avoid possible litigation. In examining charts, I look to see what other nutritional measures are instituted, which include regular dietitian involvement, use of nutritional supplements, encouragement of nutrition intake and hydration by staff, and monitoring of weight loss and food intake. We should get speech-language therapy involved to evaluate and treat dysphagia and recommend appropriate diet levels. We need to ask about patient food preferences, try to provide them, and allow family to provide preferred foods from home, as long as these foods are within dietary limitations.

And most importantly, we need to be sure of and follow patient wishes, if known, with a lot of good education and communication along the way with patient and family.

Conclusion

Perhaps the lack of appetite and associated weight loss are harbingers and signs that the patient has entered the final stages of illness that may be irreversible even in the face of aggressive interventions. It is hard to see a loved one wither away at end of life and lose a lot of weight. Geriatricians and wound care providers should remember that, despite all the medical miracles they perform on a daily basis, human mortality remains stubbornly stuck at 100%.⁴

References

1. National Pressure Injury Advisory Panel. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. 2019. Accessed March 29, 2022. www.npiap.com
2. Landi F, Calvani R, Tosato M, et al. Anorexia of aging: risk factors, consequences, and potential treatments. Nutrients. 2016;8(2):69. doi:10.3390/nu8020069
3. Li I. Feeding tubes in patients with severe dementia. Am Fam Physician. 2002;65(8):1605-1610.
4. Yankowsky KW. Avoiding unnecessary litigation: communication and documentation. Adv Skin Wound Care. 2017;30(2):66-70.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.