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Feeding Tubes May Not Help in Severe Dementia (Alzheimer's) - yet use
varies widely
July 7,
2003 - Feeding tubes may neither delay death nor improve quality of
life for nursing home patients with severe dementia, yet the use of
feeding tubes varies widely. In some states the use of feeding tubes
is more than 10 times the rate of other states, according to a new
study by Brown University researchers.
"Such
striking variation calls for increased communication among physicians,
patients prior to their developing this level of dementia, families
and nursing home regulators," said lead author Joan Teno, M.D.,
professor of community health and medicine at the Brown Medical
School. The study appears as a research letter in the June 26, 2002,
issue of the Journal of the American Medical Association.
Teno
and colleagues analyzed records for 1999 from the Minimum Data Set, a
national repository of nursing home data. The data set included
information on feeding tube use among 385,741 U.S. nursing home
residents with severe dementia.
Nationwide, about 18 percent of nursing home residents with severe
dementia had a feeding tube, with use rates varying from 3.8 percent
in Nebraska to 44.8 percent in the District of Columbia. The only
identified factor that was closely associated with the interstate
differences was physician use of "do-not-resuscitate orders" (DNRs).
For each 10-percent increase in the use of DNR orders in a state,
there was a 4.5-percent decrease in feeding tube use.
"A DNR
order is about resuscitation and should not influence decisions about
whether to use a feeding tube," said Teno. "It may be that doctors are
giving up on their patients with DNRs, so don't recommend further
treatment. This underscores the need for greater discussion about
decisions to use feeding tubes. That use shouldn't be just an
automatic process. A careful discussion is especially important for
patients who are severely demented, since medical evidence questions
whether feeding tubes improve the quality or even the length of life.
These should be broad discussions that include the community, state
regulators and consumers."
State
regulators play a critical role, Teno said. "Nursing homes are often
afraid of being cited by regulators if some of their patients are
losing weight," she said. "But near the end of life, weight loss is
exactly what happens. Physicians may believe that putting a feeding
tube in a severely demented nursing home resident will avoid that
weight loss and keep the nursing home from being cited."
Editors: State-by-state findings on feeding tube use, DNR orders, and
orders to forgo artificial hydration and nutrition will be available
at
www.chcr.brown.edu/dying/factsondying.htm when the embargo lifts
at 4 p.m. on June 26. That Web site also includes individual state
reports of pain management, site of death, number of terminally ill
patients and other information related to the nation's nursing homes.
Prior to June 26, reporters may access the embargoed information at
www.chcr.brown.edu/dying2002/factsondying.htm.
Feeding
tubes deliver liquid nourishment temporarily through the nose or
permanently directly into the stomach. They may be used in persons who
have difficulty swallowing, common in cases of severe dementia. This
difficulty in swallowing can result in weight loss and frequent bouts
of aspiration pneumonia. All are harbingers of the terminal phase of
dementia.
However, feeding tubes do not solve the problem of aspiration
pneumonia because patients often still inhale their own saliva, which
the body continues to produce, Teno said. In fact, two authoritative
summaries of current scientific evidence question whether feeding
tubes truly help delay death or enhance quality of life in patients
with dementia, she said.
No
state law prohibits forgoing or withdrawing a feeding tube. However 15
states require written evidence in an advance directive of patient
preferences to forgo a feeding tube, but this factor was not
associated with the interstate variations found by the researchers.
"Use of feeding tubes comes down to individual preferences of patients
and whether using them achieves the treatment goals that patients
value," Teno said.
Dementia often contributes to the death of nursing home residents.
Patients with the level of severe dementia in this study are bed bound
and unable to communicate. Nursing homes are increasingly the site of
death for Americans. By 2020, about 40 percent of Americans will die
in a nursing home, Teno said. "Nursing homes are our demographic
future," she said.
Teno is
also associate director of the Center for Gerontology and Health Care
Research at the Brown Medical School and medical director of Home and
Hospice Care of Rhode Island. The study's other authors are also
members of the Center. They include Vincent Mor, chair of the
Department of Community Health; Debra DeSilva, project coordinator;
Glen Kabumoto, project analyst; Jason Roy, assistant professor of
community health; and senior author Terrie Wetle, associate dean of
medicine for public health and public policy.
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