Alzheimer's, Dementia & Mental Health
Seniors with Advanced Dementia More Likely to Get
Feeding Tubes at For-Profit, Larger Hospitals
Inserting feeding tubes in
these senior citizens demonstrates a
disconnect with the existing evidence of their effectiveness
Feb. 9, 2010 - Despite being of questionable
benefit for patients with advanced dementia, new research finds that
hospitals with certain characteristics, such as those that are larger or
for-profit, are much more likely to use feeding tubes in this group of
senior citizens,
according to a study in the February 10 issue of the Journal of the
American Medical Association (JAMA).
Characteristics of advanced dementia can include
severe functional impairment, eating problems, malnutrition and
recurrent infections. Dementia is a leading cause of death in the United
States, and estimates project that 16 million individuals will have
dementia by 2050.
Medical evidence has long suggested that feeding
tubes do not improve survival or overall outcomes in patients with
dementia, a terminal illness that affect a patient's mind and eventually
the ability to eat.
"The decision to place a feeding tube in a patient
with advanced dementia is one of the sentinel decisions that family
members and health care professionals grapple with in the nursing home
environment.
Two widely cited structured literature reviews
conclude that the use of feeding tubes in patients with advanced
dementia does not improve survival, prevent aspiration pneumonia, heal
or prevent decubitus ulcers [bed sores], or improve other clinical
outcomes," write the researchers from Brown University and Harvard
Medical School.
Despite this evidence, a previous study reported
that more than one-third of nursing home residents with advanced
dementia have a feeding tube inserted, and other research has indicated
that many of these patients had their feeding tube inserted during an
acute care hospitalization, according to background information in the
article.
|
Review: Do
Feeding Tubes Help or Harm in Advanced Dementia?
April 14,
2009 - In a Cochrane review from London, doctors searched for
evidence that this intervention was beneficial.
We found
that there is no research evidence that tube feeding prolongs
survival or improves the quality of life for people with
advanced dementia, said lead author Elizabeth Sampson, M.D. In
fact, some studies suggest that tube feeding may have an effect
opposite to the desired and actually increase mortality,
morbidity and reduce quality of life.
Systematic
reviews draw evidence-based conclusions about medical practice
after considering both the content and quality of existing
trials on a topic.
This
research encompassed a review of 452 studies in seven health
care databases, five from the United States. Overall, the
studies included 1821 people, 409 of whom received some form of
tube feeding and 1467 who did not.
Just
because we found insufficient evidence of benefit does not mean
that for some individuals with advanced dementia, tube feeding
is the wrong decision, Sampson said. Each case needs to be
considered individually. We would hope that family members will
feel better informed about the pros and cons of tube feeding in
persons with advanced dementia because of this paper.
Artificially
feeding individuals with dementia is a relatively new phenomenon
that evolved after development of the percutaneous endoscopic
gastrostomy tube, or feeding PEG, in the early 1980s, said
Stephen Post, Ph.D., a professor of preventive medicine at Stony
Brook University.
Their intent
was to nourish seriously ill children until they got well, but
by 1985, PEGs became widely used as a cost-saving measure in
nursing homes, which lacked sufficient staff to do assisted oral
feedings.
The review
appeared in the April 2009 issue of The Cochrane Library, a
publication of The Cochrane Collaboration, an international
organization that evaluates research in all aspects of health
care.
>>
Complete Review |
Joan M. Teno, M.D., M.S., of Brown University,
Providence, R.I., and colleagues examined the characteristics of acute
care hospitals associated with greater rates of feeding tube insertion
among nursing home residents ages 66 years or older admitted with
advanced cognitive impairment.
Rate of feeding tube placement was based on a 20
percent sample of all Medicare Claims files and was assessed in
hospitals with at least 30 such admissions between 2000 and 2007, which
was 2,797 acute care hospitals for this study.
During the study period, 280,869 admissions
occurred among 163,022 nursing home residents (average age, 84.0 years;
67 percent women, and 12.5 percent black residents).
Between 2000 and 2007, the hospital rate of feeding
tube insertion per 100 eligible admissions decreased, from a high of 7.9
in 2000 to a low of 6.2 in 2007. The rate of feeding tube insertion
varied from 0 to 38.9 per 100 hospitalizations.
A higher rate of feeding tube insertions was
independently associated with for-profit ownership vs. hospitals owned
by state or local government, with an absolute difference of 3.0 feeding
tube insertions per 100 admissions.
Hospitals with a greater number of beds (more than
310 beds vs. less than 101 beds) also had higher rates of feeding tube
insertion, as did those with more intensive care unit use for
chronically ill patients in the last 6 months of life.
"Feeding tube insertion in persons with advanced
cognitive impairment demonstrates a disconnect with the existing
evidence of their effectiveness," the authors write.
"These results are the first to our knowledge to
document the national variation in rates of feeding tube insertions
among acute care hospitals. Future research is needed to better
understand why this variation occurs and to intervene to ensure that
feeding tube insertion reflects informed patient preferences based on
discussion of the evidence of risks vs. benefits."
"Our results suggest that decisions to insert a
feeding tube in persons with advanced dementia are more about which
hospital you are admitted to than a decision-making process that elicits
and supports patient choice," said Dr. Teno.
Second author Dr. Susan Mitchell, associate
professor of medicine at Harvard Medical school, said the data points to
a clear need to examine how treatment decisions are made for patients
with advanced dementia.
"Our results call for acute-care hospitals to
examine how decisions are made for nursing home residents with advanced
dementia, to ensure the decisions reflect patient wishes and values,"
Mitchell said.
Still, Teno said, there should always be
exceptions, particularly if the use of feeding tubes reflects a
patient's religious wishes.
"If a patient has strong religious wishes that they
receive every bit of life-sustaining treatment regardless of outcome, we
are still a society where we have to honor those wishes," Teno said.
"But we need to make sure these decisions are based on patients' wishes
and values."
Teno herself keeps in mind the Oct. 15, 2008 death
of her mother in mind following a stroke and then terminal illness.
"My mother requested that she not have a feeding
tube inserted if she became terminally ill," Teno said. "What informed
my mom's care was her wishes and values, and I want our health care
system to ensure that these important decisions consider the values and
wishes of that dying patient. As we reform our health care system,
incentives that ensure patient choice are key.
To that end, the research teams will publish
hospital rates of feeding tube insertions for persons with advanced
dementia on its Web site,
LTCFocUS.org.
Teno worked with researchers from Brown, Hebrew
Senior Life (affiliated with Harvard Medical School) and the Providence
Veterans Affairs Medical Center.
The research was funded as part of a grant and a
program project on shaping long-term care in America funded by the
National Institute on Aging and based at the Center for Gerontology and
Health Care Research at Brown.
>>
The Feeding Tube Decision for People with Advanced Dementia (pdf)
by the AGS Foundation for Health in Aging
>>
About Feeding Tube Insertion at MedlinePlus
More resources by
The AGS Foundation for Health in Aging
● Alzheimer's Association Fact Sheets: "Eating"
and "Ethical considerations: Issues in death and dying." Both available
at:
http://www.alz.org/Resources/FactSheets.asp
● Hospice and Palliative Nurses Association.
Position statement on artificial nutrition and hydration in end-of-life
care. Available at:
http://www.hpna.org/Positions.aspx
● Gillick MR, Mitchell SL. Facing eating
difficulties in end-stage dementia. Alzheimer's Care Quarterly. 2002;
3(3):227-232.
● McCann RM, Judge J. (2005) American
Geriatrics Society Clinical Recommendation: Feeding Tube Placement in
Elderly Patients with Advanced Dementia. Available at:
http://www.americangeriatrics.org/education/cp_index.shtml.
● Mitchell SL, Tetroe JM, O'Connor AM, Rostom
A, Villeneuve C, Hall B. Patient Decision Aid: Making Choices: Long Term
Feeding Tube Placement in Elderly Patients. Available at:
http://decisionaid.ohri.ca/docs/Tube_Feeding_DA/index.htm
