“Nil by mouth” feeding should be last resort for all patients, experts say

BMJ 2010; 340 doi: (Published 05 January 2010) Cite this as: BMJ 2010;340:c60
  1. Adrian O’Dowd
  1. 1London

    Patients are too often put on artificial feeding systems in hospitals to save time or because of an overly cautious approach, concludes a report published this week.

    Experts are recommending that tube feeding of patients should be adopted only as a last resort. More specialist nutrition teams are needed to advise on the most appropriate way to meet patients’ nutrition needs, they say.

    The group of experts has recommended good practice guidelines for doctors in response to concerns about the lack of consensus, particularly among clinicians, about when artificial nutrition and hydration is appropriate.

    The guidance has been produced by a working party for the Royal College of Physicians and the British Society of Gastroenterology. The working party, made up of healthcare professionals with an interest in nutrition matters, ethical experts, and patients’ representatives, reviewed clinical and ethical arguments concerning the tube feeding of patients who, often near the end of life, have difficulty in swallowing, either because of neurological illness or other substantial disabilities.

    For its report the working party invited a wide range of stakeholders to submit views. It found evidence of poor practice involving the withdrawal of oral feeding and of the inappropriate continuation of artificial feeding.

    It is estimated that about 60% of nursing home residents and 12-13% of hospital patients have difficulty in swallowing. Percutaneous endoscopic gastrostomy (PEG) feeding continues to be the most popular feeding option, because of its simplicity and low risk of complications, and is used in around 83% of cases where people are fed artificially.

    The report recommends that all trusts and care homes ensure that enough staff members are available, especially at meal times, to help and feed those patients who need a long time to eat an adequate meal.

    Nutrition support teams, ideally led by a doctor with special expertise in nutrition, should be available to work with patients and their families when patients have oral feeding difficulties.

    Clinicians are also advised that:

    • Even if a patient is deemed to have an “unsafe swallow,” a risk management approach could help them continue to eat normally

    • Where tube feeding is necessary this should be in addition to normal feeding whenever possible, and

    • Decisions about artificial nutrition and hydration should never be based on the convenience of staff or carers.

    Rodney Burnham, Royal College of Physicians registrar and co-chairman of the working party, said, “The worry is that the ‘nil by mouth’ approach is too often the first choice in cases where feeding a patient is difficult.

    “We feel very strongly that that should not be the default option. We want a sensible, balanced approach, and that’s why we recommend that a multidisciplinary nutrition support team of healthcare professionals, being collaborative, should see the patient or be available by telephone at weekends, if necessary, to advise on how to proceed.”

    Dr Burnham said that around half of hospitals had a nutrition support team already, but ideally all hospitals should have one, because help from such teams was also needed for other environments, such as care homes.

    “What we’d like to see is commissioners commissioning such a team everywhere so that no matter where the patient is they can receive expert advice,” he said.


    Cite this as: BMJ 2010;340:c60


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