It starts to look like force feeding to me

Rates of unplanned feeding tube removal have been reported at between 58%-100%1. Removal of tubes can cause distress to patients, relatives and to the staff who repeatedly replace tubes2. It affects nursing time, increases cost, increases the risk of aspiration3 and can contribute to poor nutritional status. Two methods used in the UK to reduce the risk of unplanned tube removal are mittens and nasal bridles or loops. 16 registered dietitians were interviewed as part of a qualitative phenomenological study exploring their experiences of decision-making related to artificial feeding. Convenience sampling enabled participants’ with a range of clinical experience and from a range of clinical settings to be recruited. Participants were asked about their views and experiences of the use of nasal bridles and mittens. Interviews were fully transcribed and analysed within an interpretive phenomenological framework4. Nine out of the sixteen participants had direct experience of bridles and eleven had direct experience of mittens. Identified themes were: ‘are they telling us no tube?’; ‘removes patient choice’; ‘balancing benefits and harms’; and ‘pick your patients’. Many participants believed that patients might pull tubes because they were trying to tell the team that they didn’t want to be fed: ‘Maybe they don’t want to be fed...and in a way you would be force feeding them’ P1. Many felt uneasy using bridles or mittens as they would remove a patient’s choice to remove a tube: ‘...it takes away that...freedom...of getting it [the tube] out.’ P7. When balancing benefits and harms, the participants talked of reduced quality of life, trauma of tubes being repassed, gaining full nutrition and dignity. The participants were only comfortable with their use when the right patients were selected: ‘I think if they are used in the right patient group you probably do have more success.’ P16. Balancing harm with benefits is important in ethical decision-making; all dietitians discussed this balance. One of these benefits was reducing the frequency of tube replacement which was believed to be traumatic for patients. The feeling that tube pulling may be patients trying to tell the team they didn’t want to be fed was common, however some did admit that when patients were confused this was just speculation. Removing choice was a concern for many, even though it was acknowledged that patients often lacked capacity. Many dietitians were uneasy about the use of bridles or mittens because of these concerns. Some participants believed that bridles and mittens were effective if patients were selected appropriately, for example, when patients could consent or when PEG insertion was avoided. In these situations many felt more at ease with their use. Dietitians views of use of bridles and mittens have not be reported before, but ambivalence to the use of restraints has been noted in nurses5. Many dietitians are uneasy about bridle and mitten use. Greater team discussion about patient selection and what dietitians feel about the use of bridles or mittens may help reduce some dietitians’ unease.