Forum: Give more thought and care to choice of tube

I was musing over Dr Quah Thuan Chong's letter, "Medical care and what love's got to do with it" (April 3), and wish to share what might constitute a concrete expression of love in caring for patients with dementia.

For a start, love, in this instance, is beyond sentimentality and may be construed as being committed to another's best welfare.

An inevitable yet complex issue faced in dementia care relates to decisions on tube feeding. Caregivers are perplexed when loved ones with dementia become progressively emaciated as they experience difficulties with eating and swallowing.

When dementia ravages the parts of the brain responsible for these functions, the risk of aspiration or choking is real, so pneumonia and even death threaten. Should a feeding tube be inserted under such circumstances or can oral feeding continue?

Feeding tubes, however, do not remove the risk of pneumonia altogether and are fraught with problems of their own, causing discomfort, and may lead to physical restraints being used, which may increase agitation. Whatever the option chosen, the outcome is uncertain and made more complicated when the patient cannot understand the issues or express his preference. This makes decision-making a challenge.

Decisions in such situations are best made by considering factors such as the clinical presentation and context, the patient's dementia severity, the views of the family and prior expressed wishes of the patient.

Clinicians, however, may choose to convey only the pertinent medical facts, estimates of benefits and harm, and provide little professional guidance and recommendation on the best course of action. While such an approach may carry the appeal of political correctness and even meet the minimum standards of the profession, it removes responsibility, hence falling short of love.

Instead, clinicians can draw on the principles of clinical ethics, integrated with the professional virtues of compassion, conscientiousness and courage, to help and accompany families to negotiate the crossroads in shared vulnerability.

It calls for diligence and discerning the care options to artfully secure what is in the best interest of the patient and family. Care given in this manner, together with a human touch, is perhaps what constitutes love and medicine at its finest.

Philip Yap (Dr) Board MemberDementia Singapore

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