Urban-Rural Differences in the Quality of Care for Medicare Patients With Acute Myocardial Infarction

In reply We agree that in the short term, a person with advanced de- mentia who is no longer able to swallow is likely to have life prolonged by tube feeding. While it is possible that the subjects receiving tube feeding in our study would have died sooner without it, our data do not permit us to confirm or refute this hypothesis. The important point for physicians and family decision makers is that the mortality rate was high (50% at 6 months) and equal in those treated with and without artificial nutrition and hydration. This finding has been confirmed in multiple other studies. 1-5 Tube feeding does not reverse or stabilize the progression of the underlying de- menting illness, nor does it prevent repeated aspiration of oronasopharyngeal secretions, as well as other common in- fections associated with immobility and confinement to bed or chair. Once a patient reaches this stage of illness, life ex- pectancy is limited independent of the use of tube feeding. Since a randomized trial of artificial nutrition and hy- dration in advanced dementia is unlikely from both ethical and practical standpoints, observational data of the type re- ported in our study and in others is the best we are likely to have for the foreseeable future. Families facing difficult de- cisions about whether to use tube feeding for their loved ones with advanced dementia need this kind of information to help them balance benefits and burdens with a realistic under- standing of the natural history of the disease and the high likelihood of death in a short time, no matter what treat- ments are used.