探討管灌餵食對於重度失智症老年人照護上之利與弊

The Role of Tube Feeding in the Elderly with Advanced Dementia

由於社會結構老年化，失智症的老年患者越來越多。隨著失智症病程的進展，大多數患者都會面臨進食困難及嚴重失能的問題，適切地處理進食困難的問題，是改善患者疾病末期生活品質中很重要的一環。目前臺灣在照顧有吞嚥困難的失智症患者時，採用管灌餵食的比例相當地高，然而根據過去多年來的文獻研究顯示經口餵食比管灌餵食更適合重度失智症的老年患者，因為管灌餵食不但沒有延長存活期、改善營養指標、減少壓瘡形成以及不良事件的發生，同時還可能存在一些餵食管路相關的併發症，包括新的壓瘡產生、較高的身體約束率，以及時常需要到急診室處理灌食管路相關的問題。此外，經口餵食可以讓患者繼續享受美食帶來的快樂，感受家人及照護者陪伴的溫馨。當患者本身失去表達自己意願的能力時，家屬及其醫療代理人並不需要擔心患者會因為挨餓而痛苦，而應該要考慮什麼是患者個人的最佳利益。同時，醫療照護人員也有義務和責任提供詳實的相關資訊，包括重度失智症的病程、預後、改善進食困難問題的方法與選擇，以及其相關併發症等，期望能夠規劃出最合乎患者本身意願和期待的照護模式。

Dementia is a progressive neurological disease. In the era of aging population, an increasing number of elderly with dementia are now surviving to the advanced stages of their illness. Patients with advanced dementia have a high mortality rate; also, eating and swallowing problems are likely to develop in the terminal stage of dementia. In this regard, tube feeding is often applied. However, the benefits of tube feeding have been harshly challenged during the past two decades. The best evidence to date demonstrates that tube feeding does not confer benefits in terms of nutritional status, development of pressure ulcers or aspiration pneumonia, survival, functional status, or patient comfort as compared to hand feeding. Moreover, patients on tube feeding more likely require physical or chemical restraints, and seek medical help for tube-related complications. Therefore, the widespread use of tube feeding in the elderly with advanced dementia in Taiwan should be seriously reconsidered. Current concepts suggest that hand feeding should be offered for the elderly with advanced dementia. Every effort needs to be made to enhance oral feeding and patient-centered approaches to feeding should be part of usual care for these patients. Certainly, patients or their surrogates have the right to accept or refuse tube feeding after taking into account personal wishes, advance directives and the best welfare of patients. Healthcare providers have the responsibility to promote choice, support shared and informed decision-making, and honor the preferences about tube feeding.