Eating

One thing I try to teach medical students and residents is how to answer the following question:

“When can a patient can be discharged from the hospital?”

Ideally, a patient should be able to do anything upon leaving that they could do upon entering:

Can the patient walk?

Can he poop?

Can he eat?

This last one may seem obvious, but it’s more complicated then you might think.

A recent piece in the NY Times “New Old Age” Blog addressed this issue for geriatric patients. As the article explains, swallowing is a complicated process, one which most of us take for granted because we learn to do it in early infancy and it stays with us.

Stays with us, that is, until we have a stroke or other disabling condition.

Turns out a lot of things can interfere with our ability to eat. Let’s break it down into three big categories:

Mechanical. We have to be able to break down our food, which involves mastication (chewing) and hydration (salivating). How are your teeth? If you wear dentures, do they fit right? Do not overlook your dental hygiene! Gingivitis (gum disease) leads to rotten teeth and tooth loss…which can lead to dentures. What medicines do you take? Are you on medications that cause dry mouth (too numerous to list here…)? Can you control the voluntary part of swallowing, the initiation phase? Folks who’ve had surgery or radiation to their mouths or neck may have persistent problems with these issues.

Neurologic. Are the brain and spinal inputs all there for you to swallow right? Do you have the awareness to sense when food is adequately chewed and the ability to know when to initiate swallowing? Strokes and other progressive neurologic illnesses (e.g. multiple sclerosis) can impair this part of swallowing, as well as the autonomic, or involuntary part of swallowing, which occurs after you decide to swallow, the second two-thirds of the esophageal phase of swallowing.

Lastly, absorptive. Can you actually absorb the food that you eat? By that, we mean do you have enough viable intestine to break down and absorb nutrients to fuel your body? There are people who have conditions like Crohn’s disease, whose intestines are so inflamed (or have been surgically removed because of it) that lack sufficient absorptive capacity. Eating a regular diet can cause dumping syndrome, where food that’s eaten goes right through the gut without being adequately broken down or absorbed. It can be extremely debilitating.

Fortunately, with modern methods, we can solve these problems–though none of the answers are great.

For mechanical and neurologic problems, we can place a feeding tube directly into the stomach. This allows you to put well-balanced protein shakes (that you don’t taste, since they go right into the stomach) into your digestive system. This nifty solution bypasses a disordered swallowing mechanism. Those with swallowing disorders are at risk of aspiration, which means food going into the airway which can cause “aspiration pneumonia.”

For absorptive problems, we can feed you parenterally, or outside of your digestive tract, by using IV formulas of basic food molecules: proteins, fat, and carbohydrates. People can live for years this way, sustaining themselves, but the dangers of IV line infections and blood clots make this less than ideal.

And this whole issue can get particularly thorny near the end of life: Would your Mom, Dad, or Grandma, if incapacitated, want to be kept alive with a feeding tube of either variety? It’s extraordinarily difficult to be put in the position of deciding not to feed a loved one. It can feel callous, as though you want to starve them. But for some people, in some conditions, it can be the correct choice.