Tuesday, August 28, 2012

The Doctor Won't Order Intravenous Nutrition

Hello, I have a concern I hope you can help me with. My mother, who has always been in good health, is now in her 80s and has started to have her health fail. She is in the hospital for work-up, finally, but suffers from a very poor appetite and weight loss. It seems she won't be able to fight whatever is wrong without building up her strength. We have asked the doctor to start intravenous nutrition (they call it TPN) but he refuses. He says he can have a tube put into her stomach to feed her, but we feel this is quite invasive. What do you make of the situation?
Kevin T.

Hello Kevin,

I'm sorry to hear your mother is ill. I have seen cases just like this over the many years I've worked in hospitals as a clinical dietitian to help patients become as well-nourished as possible. Your doctor is, in my opinion, giving you the best and safest option. 

While a tube into the stomach may seem invasive (whether it is threaded through the nose, or through a small opening made in the skin near the stomach), it maintains the body's usual form of receiving nutrition. Nutrients go directly into the digestive system. There are very few risks with these tubes. Perhaps the most serious is aspiration, where the formula can regurgitate and end up going into the lungs. (This happens most often in unresponsive patients who cannot sit up and may not have their normal swallow reflex).

Intravenous (or Total Parenteral Nutrition) feeding consists of making an opening into a large vein and delivering concentrated sources of nutrients that do not require digestion. The side effects of this procedure are numerous: Complications during the surgery can be serious; once the line is in place it's an opportunity for infection, and bacteria entering into the blood stream has quite severe consequences; nutrient delivery does not go through the usual route and causes some abnormalities in liver function; high blood sugars are common, and triglycerides can rise in the blood to potentially hazardous levels; over-feeding can occur and it can be difficult to maintain normal mineral and electrolyte levels while on TPN. And finally, not using the gastrointestinal tract leads to atrophy of the cells in the intestine, which are actually an important part of the body's immune system.
The only reason TPN should be used is when the GI tract cannot be used (severe vomiting or diarrhea, blockage, or removal of part of the intestine prohibiting feeding into the gut).

In cases such as your mothers, the dietitian should be called in to consult, and steps taken to work from least to most invasive. First, your mother should be offered foods she likes; secondly she should be offered snacks or smaller meals so she has more chance of taking in enough nutrition if her appetite is small; third is the offering of nutritional supplements like Ensure or Boost, which can provide hundreds of calories with mere sips of the drink taken all day long; another option is prescription appetite stimulants which work very well in some patient populations. Finally, once the source of her illness is discovered, working to treat that may cause her appetite to return.

Tube feedings are one of the last options (largely because the patient is not often willing to have one placed) but are an extremely important weapon in combating malnutrition. Low body weight, low blood protein levels, and minimal nutritional intake may call for this intervention. And better sooner than later.
TPN is THE last option and should not be considered unless there are no other options to nourish your mother, or any other patient.

I hope your mother feels better soon. If you don't see her poor intake being aggressively addressed, ask for the dietitian to be consulted and keep in touch with her about your mother's plan of care.

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