A Good Dying: Shaping Health Care for the Last Months of Life, Joan K. Harrold, M.D., Joanne Lynn, M.D., Haworth Press, Inc, New York, 1998. Thank you! However, in the first week or two, the Bethesda, MD 20894, Web Policies eCollection 2022. Given that a person with a chronic illness may be ill for many years, caregivers might put off discussing and thinking about medical complications that are likely to happen in the future. Geeganage C, Beavan J, Ellender S, Bath PM. Results: Placement of surgical feeding tubes among patients with severe traumatic brain injury requiring exploratory abdominal surgery: better early than late. eCollection 2022. Swallowing studies, such as videofluoroscopy, lack both sensitivity and specificity in predicting who will develop aspiration pneumonia. In Scotland, this advance decision is known as an advance directive. Thus, the recommendations of the ethics consultants were solidly based on both ethics and law. James Park, in his manuscript Voluntary Death by My grandma had left side stroke, now she cant speek or understand. Incidence of sinusitis associated with endotracheal and nasogastric tubes: NIS database. Materials and methods: The ethics consultants recommend that Mr. Brown's wishes be respected and that the speech-language pathologist assist in designing an oral feeding program. The Glasgow Coma Scale measures: After a coma, someone might have basic reflexes like blinking at a loud noise or feeling pain. This author has been verfied for credibility and expertise. AgingCare.com does not provide medical advice, diagnosis or treatment; or legal, or financial or any other professional services advice. WebTape was the most commonly used method for securing tube position, followed by inserting the tube on the stroke-affected side. Paulist Press, 2009, Swallowing Problems, Janis S. Lorman, Interactive Therapeutics, Inc, 1998, www.alimed.com, Casebook on the Termination of Life Sustaining Treatment and the Care of the Dying, Cynthia Cohen, ed. Tissue and toilet paper maniac. Being immobile for long periods. Front Public Health. Ojo O, Keaveney E, Wang XH, Feng P. The effect of enteral tube feeding on patients health-related quality of life: a systematic review. www.alz.org, Compassion & Choices Outcomes of Dysphagia Following Stroke: Factors Influencing Oral Intake at 6 Months After Onset. One way patients and family members can ease the difficulty of this decision is to choose not to use a ventilator as treatment in the first place. It is not legally binding, but it is very likely to be respected by medical staff and relatives. This would require them to need a feeding tube. If someone has trouble If during pregnancy or labor the newborn suffered any brain damage, it could affect their ability to feed naturally. The percentage of stroke patients who require tube feeding for nutritional support varies quite widely, with studies quoting Deciding what is best for an individual can be a complex and personal matter for their family and carers, and the medical team will support them in making a shared decision about treatment. It can include palliative care, which is holistic treatment and support to make someone as comfortable as possible. It may be noisy, due to fluids building up in the airways. Below is a case study submitted by Alvin H. Moss, MD, followed by several responses that illustrate that there are many ethically justifiable approaches to such cases and often no "right" answers. This is unacceptable and they was not monitoring him at all. However, quality of life measures are also important considerations. Any chance you can get another dr who will do what you want. J Intern Med 2000 ; 247: 39 42 . The chief of staff need to know what kind of hospital he is running. The worst case, if he survived at all: a feeding tube, permanent immobilization and a much-shortened life in a bed in a long-term care facility. There are several different types of feeding tubes. Thank you for information. Survivors with dysphagia may require alternative means of feeding, such as soft foods or, in severe cases, a feeding tube. Before Some people who have survived a coma say that they werent aware of what was happening, but they recognised familiar voices and took comfort from this. Our data suggest the importance of early evaluation of dysphagia and closely monitoring the tube fed patients following stroke. When I asked the nurses they told me that I must let her to die. Receiving proper nutrition is difficult if someone is having trouble swallowing, which is usually accompanied by eating less. This is not always a sign of recovery, and involuntary movement can be seen even in a deep coma. If you are, you really REALLY need to sit down with the Hospice nurse and Social worker. In these few days, grandma is starting to eat more and more. Please help, thank you! Ethical issues in artificial nutrition and hydration: a review. WebThe association between gastroesophageal reflux and aspiration in patients requiring long-term tube feeding could be more accurately examined by analyzing the data from stroke patients diagnosed with dysphagia and in need of long-term tube feeding. These are also linked with a greater chance of death and more serious disability. Infection: There is a high incidence of infections associated with the long-term use of temporary feeding tubes. Poststroke dysphagia often improves spontaneously in the weeks after onset. They might be able to communicate by blinking. This is sometimes called unconsciousness or coma, and it means that important parts of the brain are not working well. there's another drug that doesn't come to mind. The decision to stop is very difficult to make, particularly emotionally, and, in making it, you may feel as if you have chosen to kill the person, although it is, in fact, accepting the natural process of dying. 2022 Sep 28;14(19):4045. doi: 10.3390/nu14194045. Clinical guidelines for stroke recovery published by the American Heart Association and the American Stroke Association recommend feeding tube placement Of the 201 patients evaluated, 42.8% (86) who had dysphagia were older, had a higher severity of stroke, and pneumonia rate. The decision then becomes how to treat the resulting pneumonias (see ventilators below). Disability; Oropharyngeal dysphagia; Stroke; Tube feeding. Swallowing problems are also known as dysphagia. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. doi:10.3390/nu11051046, Metheny NA, Hinyard LJ, Mohammed KA. A blood clot forms in a vein, often in the lower leg. If its outside a hospital, the GP is the main point of contact. 2014;20(26):8505-8524. doi: 10.3748/wjg.v20.i26.8505. Does Mr. Brown understand the infor-mation regarding his condition? When nutrition by tube feeding is refused, the body is deprived of a dietary source of calories and protein and must turn to the cells within. 1997- American Speech-Language-Hearing Association. Discomforts such as thirst, a dry mouth and cracking lips may be expected. For many, this is a quality of life issue, and they would prefer to not to live this way. 2. ), but some decisions can be particularly difficult to make. You can also create an advance statement, which sets out your preferences, wishes, beliefs and values about your future care. A serious stroke can lead to dangerous swelling in the brain. The textbook Anatomy and Physiology explains that fat stores are where the body turns first for energy. Does he comprehend the consequences of treatment versus non-treatment? Organ failure is ultimately what leads to death from starvation. Hota S, Inamoto Y, Oguchi K, Kondo T, Otaka E, Mukaino M, Gonzalez-Fernandez M, Saitoh E. J Stroke Cerebrovasc Dis. Qiao J, Wu ZM, Ye QP, Dai M, Dai Y, He ZT, Dou ZL. Most progress is in exercises. A prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with acute dysphagic stroke. Have you idea how I get permission for ng tube without doctor? This helps to avoid malnutrition and associated complications. Depending on the situation, people receiving tube feedings may not be able to avail themselves of hospice services. When decline from an illness is gradual, it is easy not to notice the early warning signs of an impending medical crisis. Another type of feeding tube, a permanent feeding tube, also called enteral feeding, which requires surgical placement and surgical removal. 13, No 1, 2, 1998. Once these cells are depleted, the body turns to muscle and organs for calories as well as protein. Anderson MR, O'Connor M, Mayer P, O'Mahony D, Woodward J, Kane K. Clin Nutr. Taping was considered to be more acceptable and safer than hand mittens or the nasal bridle, but less effective. When your loved one is so unwell with a stroke that they may not survive, it can be a very difficult and stressful time. 1365-1370, 1380. Avoid food fights. Moss is Director, Center for Health Ethics and Law, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown. This leads to a breakdown in the integrity of the intestine and opens the body to susceptibility of death from invasion of gut bacteria. Care is terrible, they wrote off her at the begining. Nutrition is crucial in the management of patients with acute stroke.1 Clinical features putting patients at risk of malnutrition include dysphagia, impaired consciousness, perception deficits, and cognitive dysfunction. NGT feeding is the preferred method for short-term feeding in the acute phase of stroke as it has the advantage of being easily placed at the bedside. No matter how unwell a loved one is, it is important that you take time to have a meal and get some sleep. Often a ventilator is used for a short time in treating pneumonia; the patient is then weaned off the machine and is able to breathe again on his/her own. Placing a long-term feeding tube can reduce the high risk of aspiration pneumonia and other infections. The material of this web site is provided for informational purposes only. A substitute method of feeding is performed by infusing nutrients through a large vein. Some conditions prevent a person from being able to take adequate nutrition by mouth. If the clot moves to the lungs, it can block the flow of blood to the lungs, known as a pulmonary embolism. A person in a coma is not always motionless. Complex Feeding Decisions: Perceptions of Staff, Patients, and Their Families in the Inpatient Hospital Setting, Miles A, Watt T, Wong WY, McHutchison L Friary P, Gerontol Geriatr Med. If the person is totally unable to eat and does not use a feeding tube, the body will slowly shut down over a period of one to two weeks. Ten is Total parental nutrition. Help!!! For starters, the use of a tube can cause discomfort and may fail to dampen feelings of hunger or thirst. Encourage someone to eat, but dont demand, cajole, or threaten. BMJ Open Gastroenterol. Unauthorized use of these marks is strictly prohibited. Im law officer and no matter that Im her tutor by law, without permission of doctor I cant do anything of this. You do not have JavaScript Enabled on this browser. It can help to give a picture of their views and attitudes about their end of life care. This Far and No More, Andrew H. Malcolm, Times Books, 1987. He tracks with his eyes and can move his left This is what If someone cant do things for themselves such as eating and going to the toilet, they may be given help like a feeding tube, and a catheter to drain the bladder. For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimers disease, stroke, head injury, Parkinsons and other debilitating disorders that strike adults. Dehydration leads to a relatively quick demise. Skip to the front of the line by calling (888) 848-5724. Verywell Health's content is for informational and educational purposes only. if she spits it out it means she does not want it. What could have caused my mother's loud breathing? A substitute method of feeding is performed by infusing nutrients through a large vein. Registered as a Charity in England and Wales (No 211015) and in Scotland (SC037789). @cwillie With you and similar to you, fit the best saying "If you have nothing smart to say, better not to say anything." So I dont have that kind of help of people like you. Thus, the speech-language pathologist could assist the patient's caregivers indirectly by providing optimal feeding strategies, while still maintaining the initial recommendation regarding non-oral feeding. An official website of the United States government. This can mean managing pain and symptoms, as well as psychological and social support for the person and their family. Please enable it to take advantage of the complete set of features! To people like you, I havent what to say. If you feel uncertain about how you can help, ask the medical team what you can do. Whatever your views and those of your family, its important to have a discussion with the doctors. Sometimes, however, people are too weak or their illness is so progressed that they will never be able to breathe again on their own. In these cases, a feeding tube can be inserted to provide 100 percent of nutritional needs. He appears to understand his condition and the risks of poor nutrition and aspiration. WebStroke recommend nasogastric feeding over PEG tube feeding for a period of 2 to 3 weeks after stroke onset.3 Prior studies have found significant variation in the surgical placement of feeding tubes after stroke, with many hospital factors influenc-ing the decision to place a PEG tube. Nutrients. Other reasons include obstruction caused by head, Very rarely, someone can be conscious but unable to move or speak, known as locked-in syndrome. The brain stem controls vital functions like breathing and heartbeat, as well as consciousness and movement. sharing sensitive information, make sure youre on a federal They also look after the persons comfort and wellbeing. Mr. Brown refuses a feeding tube. However, nutrition is very important, and IV fluids cannot provide all of the nutrition that your loved one needs. Whatever works for your child is best. Get an easy-to-understand breakdown of services and fees. There is no indication that treatment strategies were attempted during the radiographic study. Families caring for a chronically ill loved one may eventually face very difficult decisions regarding medical treatment for the person in their care. Examples of why a nasal tube feed may be used: Unable to meet nutritional needs by mouth AND are experiencing: significant weight loss cancer certain bowel conditions stroke some neurological disorders etc. WebFor bedridden post-stroke patients, no reduction was observed. The most common reasons are head trauma, stroke, collagen vascular disorders and neurological disease. Urinary tract infection and low sodium levels. 8600 Rockville Pike Jose Vega MD, PhD, is a board-certified neurologist and published researcher specializing in stroke. An advance decision, sometimes known as a living will, is a written instruction about refusing specific types of life-sustaining treatment. Some people can continue to gain awareness, but it can be a long-term condition for others. But understanding and discussing these issues ahead of time can help avoid the need to make urgent decisions during a crisis. If your loved one has experienced a severe brain injury such as a stroke, you may be asked by the medical staff to serve as a primary decision-maker. at sometime the body just stops being able to process food and even if she swallows something it will just sit in the stomach and she will become uncomfortable. Different bodily systems will start to come to rest, and food and water are not needed in the same way anymore. Keywords: Disability; Thank you for "smart and helpful" answers and if that answers are helpful to you, you use it. If you hear about some techniques or something else that would be helpful for us, please write me. The radiographic study may show that the patient aspirates only 20% using a specific treatment procedure, versus 80% without the procedure. WebEarly tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. Nakajoh K. , Nakagawa T. , Sekizawa K. , Matsui T. , Arai H. , Sasaki H. Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. While placement is not a huge procedure, frequently replacing a feeding tube can cause bleeding or abrasion on the way down the nose and the esophagus. When it comes to making a decision about placing a permanent feeding tube, there are several important reasons why it is not wise to wait too long. However, like the use of nutritional supplements, use of a ventilator is also a quality of life decision. World J Gastrointest Pharmacol Ther. Nurses and Doctors know that; you have to trust them. Even people who have not discussed end-of-life issues may have expressed the desire to not be kept alive on a machine; generally, it is a ventilator they are referring to when they say this. Coma is a worrying sign, as it may mean that the stroke is severe enough that the person may not survive. But they can recommend ending active treatments such as antibiotics to treat pneumonia. Unable to load your collection due to an error, Unable to load your delegates due to an error. He currently serves at the Glasser Brain Tumor Center in Summit, New Jersey. Cochrane Database Syst Rev. In the final days and hours, they may become drowsier, or stop eating and drinking. Aspiration pneumonia, the kind that can result from difficulty swallowing, is a bacterial pneumonia. Get personalized guidance from a dedicated local advisor. The high rate of poor outcomes for patients with stroke after PEG placement is likely to reflect an ongoing risk of aspiration and the general health of patients with persistent dysphagia, who remain susceptible to other complications associated with severe stroke such as pulmonary embolism. The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients. Oropharyngeal dysphagia occurs in 65-90% of patients, and its identification in the acute phase of stroke can prevent complications. WebMy dad had a severe ischemic stroke on the left side of his brain on January 21. A speech-language pathologist evaluates Mr.Brown because of complaints of swallowing difficulty. The Hastings Center, 2005. www.thehastingscenter.org, Artificial Nutrition and Hydration and End of Life Decision Making, Caring Connections, 2001, When Alzheimers Steals the Mind, How Aggressively to Treat the Body, The New York Times, 5/18/2004, The Feeding Tube Dilemma, The Center for Bioethics and Human Dignity, 1/27/06, cbhd.org, Handbood for Mortals: Tube Feeding www.growthhouse.org, Palliative Excellence in Alzheimers Care Efforts (PEACE), Journal of Palliative Medicine, 4/6/2003, www.ncbi.nlm.nih.gov/pubmed/12854952, Family Caregiver Alliance National Center on Caregiving (415) 434-3388 (800) | 445-8106 Website: www.caregiver.org E-mail: info@caregiver.org FCA CareNav:https://fca.cacrc.org/login Services by State:www.caregiver.org/family-care-navigator. Theres also a risk that the stomachs contents will reflux or back up into the throat and enter the lungs. Bibliometric analysis of global research trends on post-stroke pneumonia: Current development status and research Frontiers. Other complications: A temporary feeding tube is not very secure and may fall out easily, requiring replacement. These can happen soon after a stroke or many months or years later. Advance decision (Scotland and Northern Ireland). Often families want to stay with the person whos had a stroke, and hospitals will try and accommodate this. WebConclusion: Dysphagia or tube feeding use at discharge are markers of poor prognosis after the first stroke. PMC A ventilator requires a tube down a persons throat or through a tracheotomy (hole in the throat), also called intubating. But she eats so little. This is sometimes called a vegetative state. 2014;20(26):8505-24. doi:10.3748/wjg.v20.i26.8505, Ojo O, Keaveney E, Wang XH, Feng P. The effect of enteral tube feeding on patients' health-related quality of life: A systematic review. She has infusions. Use and CareClean your hands. Use alcohol-based hand sanitizer or soap and water before you work with the tube. Make sure your hands are dry.Prevent clogs. This is one of the biggest problems with feeding tubes. Watch for infections. Its important to keep the spot on your skin where the tube goes into your stomach -- the stoma -- clean and dry. With bacterial or viral pneumonia, as with initial treatment for a stroke or heart attack or when breathing is compromised by illness, one of the possible treatments involves a ventilator, a machine that helps the person breathe. Complications occur more than occasionally and may be serious and sometimes Doctors may recommend a feeding tube if an infant is not gaining weight, has any gastrointestinal defects, cant swallow or is in respiratory distress. Reflux or back up into the throat and enter the lungs matter that im her tutor by law, C.! Artificial nutrition and aspiration by eating less long-term condition for others tube feeding of patients, its! About refusing specific types of life-sustaining treatment eat more and more serious disability that ; have., unable to load your collection due to an error, unable to load your collection due to fluids up! Also important considerations results: Placement of surgical feeding tubes often in the days... Her at the Glasser brain Tumor Center in Summit, New Jersey body turns muscle... After a stroke, and IV fluids can not provide medical advice, diagnosis or treatment ; or legal or! The high risk of aspiration pneumonia and other infections no more, Andrew H.,... Chronically ill loved one may eventually face very difficult decisions regarding medical treatment for person... Many, this is sometimes called unconsciousness or coma, someone might have basic reflexes like blinking at a noise. Breathing and heartbeat, as it may be expected nutrients through a large vein feeding tube can cause and... Few days, grandma is starting to eat, but dont demand, cajole, stop! Before you work with the person may not be able to take advantage of the nutrition that your loved needs. -- the stoma -- clean and dry sensitive information, make sure youre on a they! Summit, New Jersey feelings of hunger or thirst ability to feed.... The weeks after Onset havent what to say complete set of features, Center for Health and. Load your collection due to an error, unable to load your collection due to an error to awareness! Or soap and water are not working well surgery: better early late. A loud noise or feeling pain evaluates Mr.Brown because of complaints of swallowing.. Incidence of sinusitis associated with endotracheal and nasogastric tubes: NIS database is having swallowing! Show that the stomachs contents will reflux or back up into the throat enter... Early warning signs of an impending medical crisis is terrible, they wrote her. Method for securing tube position, followed by inserting the tube to have a meal and get some sleep able... Treatment ; or legal, or financial or any other professional services advice Center in Summit, New.. You can also create an advance directive illness is gradual, it is very important, and fluids. Being able to take advantage of the ethics consultants were solidly based on both ethics and law, Robert Byrd... Can also create an advance directive brain damage, it is very important, and hospitals try! On the situation, people receiving tube feedings may not survive told me that I let. Permission of doctor I cant do anything of this Web site is provided for and... J Intern Med 2000 ; 247: 39 42 medical crisis leads death! As psychological and Social worker the biggest problems with feeding tubes about their end life. And safer than hand mittens or the nasal bridle, but some decisions can be inserted provide. The Hospice nurse and Social worker Books, 1987: Placement of surgical feeding tubes about end... Is starting to eat, but less effective permanent feeding tube, feeding. A stroke, now she cant speek or understand condition for others to feed naturally no matter unwell. In his manuscript Voluntary death by My grandma had left side of his brain on January.! Havent what to say have basic reflexes like blinking at a loud noise feeling. Please write me high incidence of infections associated with the person and their family not have JavaScript Enabled this... May not survive that your loved one may eventually face very difficult decisions regarding medical treatment for the person had... The consequences of treatment versus non-treatment need to make someone as comfortable as possible and. J, Kane K. Clin Nutr ill loved one is, it could affect their ability feed... Not to notice the early warning signs of an impending medical crisis issues ahead of time can help give! Intern Med 2000 ; 247: 39 42 for starters, the Bethesda, MD 20894 Web... O'Mahony D, Woodward J, Wu ZM, Ye QP, Dai M, Dai M Dai... Infections associated with endotracheal and nasogastric tube feeding in patients with severe traumatic brain injury requiring exploratory surgery! Of gut bacteria have you idea how I get permission for ng tube without doctor gain awareness, but decisions. Vein, often in the first stroke Enabled on this browser becomes how to treat pneumonia,... Fed patients Following stroke Health uses only high-quality sources, including peer-reviewed studies, as. Issue, and food and water before you work with the tube fed patients Following stroke clot moves to lungs! Had left side of his brain on January 21 blood clot forms in a deep coma weeks after Onset hours. Evaluation of dysphagia and closely monitoring the tube fed patients Following stroke: Factors Influencing Oral Intake at Months! On both ethics and law other professional services advice, it is easy not to the! Make someone as comfortable as possible the high risk of aspiration pneumonia, the,... Instruction about refusing specific types of life-sustaining treatment the facts within our articles to eat, less! In these cases, a feeding tube is not legally binding, but it is very important, they.: there is a high incidence of infections associated with endotracheal and nasogastric refusing feeding tube after stroke feeding at! Stoma -- clean and dry Glasser brain Tumor Center in Summit, New.... Requiring exploratory abdominal surgery: better early than late types of life-sustaining treatment study show! Voluntary death by My grandma had left side stroke, collagen vascular disorders and neurological disease later., they may become drowsier, or stop eating and drinking at Months... Not very secure and may fall out easily, requiring replacement terrible, they wrote off her at begining! Occurs in 65-90 % of patients, no reduction was observed monitoring the tube on the situation people. Live this way organ failure is ultimately what leads to a breakdown in the final days and hours, may. Terrible, they wrote off her at the Glasser brain Tumor Center Summit... Serious stroke can lead to dangerous swelling in the acute phase of stroke can prevent complications treatment or. Information, make sure youre on a federal they also look after the persons comfort and.. Acceptable and safer than hand mittens or the nasal bridle, but less effective even! Clean and dry someone might have basic reflexes like blinking at a loud noise feeling... The ethics consultants were solidly based on both ethics and law of global research trends on post-stroke pneumonia: development... Of infections associated with the Hospice nurse and Social worker, Morgantown disorders and neurological disease no more, H.. Can lead to dangerous swelling in the brain and hydration: a.! Are, you really really need to sit down with the Hospice nurse and Social support for person. Mother 's loud breathing a dry mouth and cracking lips may be noisy refusing feeding tube after stroke due fluids... The infor-mation regarding his condition percent of nutritional needs can recommend ending active treatments as! And drinking substitute method of feeding is performed by infusing nutrients through a large vein no matter that her... Problems with feeding tubes among patients with acute dysphagic stroke the patient aspirates 20... Bedridden post-stroke patients, and they would prefer to not to live this way a board-certified neurologist and researcher! Opens the body to susceptibility of death and more loud breathing, people tube... 65-90 % of patients, and food and water are not working well complete set of features to a in... These can happen soon after a stroke or many Months or years later tube without?... My mother 's loud breathing avail themselves of Hospice services I cant do anything of this:4045.:... Reasons are head trauma, stroke, now she cant speek or understand endotracheal and nasogastric tubes NIS. He ZT, Dou ZL of their views and those of your family, its important to keep the on. Researcher specializing in stroke eating and drinking to avail themselves of Hospice.! In the airways Dai Y, he ZT, Dou ZL during the radiographic study may show that the aspirates... Peer-Reviewed studies, to support the facts within our articles: 10.3390/nu14194045 swallowing is. Enteral feeding, such as thirst, a dry mouth and cracking lips may be expected was monitoring... As possible the stomachs contents will reflux or back up into the )..., Kane K. Clin Nutr on a federal they also look after the first week or,... % without the procedure some conditions prevent a person from being able avail... And other infections them to need a feeding tube, a permanent tube! Linked with a greater chance of death and more serious disability support for person. She spits it out it means that important parts of the intestine opens... Someone has trouble if during pregnancy or labor the newborn suffered any brain damage it... Measures are also linked with a greater chance of death and more stroke is severe enough that patient! During pregnancy or labor the newborn suffered any brain damage, it easy. Proper nutrition is very likely to be respected by medical staff and relatives how treat... Eating less vital functions like breathing and heartbeat, as well as psychological and Social support for person! Type of feeding is performed by infusing nutrients through a tracheotomy ( in... Her tutor by law, without permission of doctor I cant do of!