Advancing a Palliative Approach in Dementia Care in Asia: De‐Implementation of Tube Feeding as Litmus Test

Dementia prevalence is rising sharply in Asia, with projections that over half of all individuals living with dementia will reside in the region by 2050 [1]. The World Health Organization's Global Action Plan on Dementia (2017–2025) recognizes palliative care as a core component of dementia care, emphasizing dignity and person-centeredness throughout the disease trajectory [2]. The article by Malhotra and colleagues is both timely and significant, drawing attention to the absence of a palliative approach in dementia care across Asia, despite the region bearing the greatest burden of disease [3]. Their use of the Consolidated Framework for Implementation Research (CFIR) provides a structured lens to analyze barriers and facilitators across the outer setting, inner setting, and individual levels [4]. This framework is particularly useful in guiding research and policy recommendations to advance a palliative approach to dementia care. Malhotra's review identifies multiple barriers. In the outer setting, few national dementia strategies include palliative care guidance, and financing mechanisms for community-based palliative care are inadequate. In clinical practice, guidelines are limited and inconsistently implemented. Sociocultural values, such as filial piety and family-led decision-making, favor life-prolonging interventions, often at the expense of autonomy. Inner setting challenges include underdeveloped healthcare infrastructure in long-term care and home care services and limited professional training in end-of-life dementia care. While cultural norms of caregiving as a duty motivate home-based care, limited caregiver support contributes to high caregiver burden and burnout. On the individual level, the public has limited understanding of dementia as a terminal illness which contributes to low uptake of advance care planning (ACP) for people with dementia. Still, high digital readiness across many Asian societies offers opportunities to leverage technological innovations for dementia care [3]. Among the low value practices that are prevalent in dementia care in Asia, reliance on tube feeding in advanced dementia serves as a compelling case study. While Western countries have made significant strides in reducing this practice, Asia lags behind. This divergence offers a powerful lens to examine systemic, cultural, and clinical barriers, and to identify drivers that can be adapted for Asia. The prevalence of tube feeding in advanced dementia has declined significantly in Western countries. In the United States, rates among nursing home residents dropped from over 30% in the early 2000s to less than 10% in recent years [5]. Similar declines are reported in the United Kingdom and Europe, reflecting widespread recognition of tube feeding as a low-value practice [6]. By contrast, studies from Singapore, Japan, Taiwan, and Hong Kong report high rates of tube feeding, with some nursing homes reporting rates as high as 30%–60% [6-10]. Several drivers contribute to the significant de-implementation of tube feeding in Western countries. First, the evidence base is strong. Multiple observational studies conducted in this region show no survival benefit or reduction in aspiration pneumonia with tube feeding compared to oral feeding [11]. National guidelines from the American Geriatrics Society (AGS) and the European Association for Palliative Care (EAPC) discourage tube feeding and promote careful hand feeding as the standard of care [12, 13]. Choosing Wisely campaigns in the United States, Canada, and Europe have identified tube feeding as a low-value practice, embedding this into institutional policies and quality metrics [6]. Financing models also have played a role. Medicare hospice benefits in the United States and universal coverage in the UK's National Health Service have reduced financial barriers to palliative care. At the inner setting level, established long-term care infrastructure has supported hospice and palliative care integration, while palliative care education has been embedded in medical and nursing curricula. Asia faces a different reality. Region-specific evidence on nasogastric tube feeding, the predominant type of enteral feeding used, is limited, although the evidence base has been growing in recent years [14, 15]. Few national guidelines exist, and where they do, implementation is inconsistent [3]. Cultural emphasis on filial piety reinforces tube feeding, as withholding artificial nutrition is often perceived as a failure of duty [16]. Healthcare system constraints are significant. Underdeveloped long-term care infrastructure and staffing shortages make hand feeding difficult in institutional settings. While careful hand feeding programs in Hong Kong have shown promise to reduce tube feeding rates [17], these programs are limited to hospital settings, and community-based programs remain lacking. Professional training gaps and medicolegal concerns drive default reliance on tube feeding and restraints. At the individual level, low dementia literacy and limited ACP uptake lead to unrealistic expectations and default use of life-prolonging interventions [3]. De-implementation of tube feeding practices in Asia requires not mere transplantation of drivers that have worked in Western countries, but adaptation and innovation. Malhotra's article provides a roadmap. At the outer setting level, culturally adapted metrics for “quality of dying with dementia” should be developed, discouraging tube feeding while respecting family-centered decision-making. National dementia strategies must integrate explicit palliative care guidance, and financing reforms should incentivize community-based care and enable staffing to support hand feeding. Legal and regulatory frameworks should also clarify standards of care for feeding decisions in advanced dementia to reduce defensive practices and medicolegal anxiety among frontline providers and carers. At the inner setting level, training and culture change for care providers are crucial, alongside community-based models to support careful hand feeding, especially in long-term care settings that serve a large proportion of people with advanced dementia. Dementia-specific palliative curricula must be integrated into the training for healthcare professionals and caregivers. At the individual level, ACP should be normalized through culturally sensitive approaches. Public campaigns are needed to provide education on the lack of benefit of tube feeding while promoting comfort feeding approaches as consistent with cultural values of filial piety and respecting the dignity of elders. Strengthening caregiver support infrastructure will reduce distress and caregiver burden and help to shift away from reliance on tube feeding. Research to explore the perspectives of individuals with dementia and caregivers on tube feeding decisions can help to develop tailored strategies to address barriers. Technological innovations can be leveraged to support tube feeding de-implementation, such as developing scalable decision aids and training modules for caregivers. De-implementation of tube feeding is not merely a clinical decision—it is a litmus test for whether health systems can truly embrace a palliative approach to dementia care. It illustrates that advancing palliative care approaches requires changes at the systems, organizational, and individual levels. Malhotra and colleagues propose a research agenda that provides a roadmap for important reforms that are needed: de-implementation of low-value practices, implementation of community-based models, leveraging technology, and developing standardized metrics tailored to Asian contexts. These recommendations are timely and urgent. But the broader message is clear: Asia's dementia care must pivot from prolonging life at all costs to preserving personhood at the end of life. De-implementation of tube feeding is not merely a clinical decision—it is a litmus test for whether health systems can truly embrace a palliative approach to dementia care. It illustrates that advancing palliative care approaches requires changes at the systems, organizational, and individual levels. J.K.Y. was solely responsible for the conception, drafting, and final approval of this editorial. The author has nothing to report. The author has nothing to report. No external sponsor played a role in the design, preparation, or submission of this editorial. The author declares no conflicts of interest. This publication is linked to a related research article by Malhotra et al. To view this article, visit https://doi.org/10.1111/jgs.70283.