So, what do you think about this story? Study: End-of-life care must reflect patient wishes and values
Researchers from Brown University and Harvard Medical School are calling for improved decision-making in the use of feeding tubes for hospitalized nursing home residents with advanced dementia.
Their position follows an eight-year study, which found that the use of feeding tubes varies widely. Among their major findings: At 25 percent of the nation's acute-care hospitals, this vulnerable population had a one in 10 chance of having a feeding tube inserted. Twelve percent of acute-care hospitals did not insert a feeding tube at all.
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.
Details of the study are outlined in the Feb. 10, 2010, issue of JAMA, the Journal of the American Medical Association.
"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. Joan M. Teno, lead author and professor of community health and medicine at the Warren Alpert Medical School of Brown University.
The range of feeding tube use varies widely. Researchers found the rate of feeding tube insertions per 100 hospital admissions varied from 0 to 39, depending on the hospital. On average, 6.5 out of every 100 admissions resulted in a feeding tube insertion.
Teno and the other researchers conducted their study by looking at nearly 2,800 acute-care hospitals. They sifted through Medicare claim files involving more than 280,000 admissions from 2000 to 2007 to determine the rate of feeding tube insertions among hospitalized nursing home residents over age 66 with advanced dementia. They looked at hospitals with at least 30 admissions involving nursing home residents with advanced dementia during that period.
Hospitals with a culture of aggressive care at the end of life were nearly three times more likely to insert a feeding tube, according to the study.
Larger or for-profit hospitals tended to use them more. Smaller, rural hospitals not affiliated with medical schools used them far less frequently.
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.
Re: Study: End-of-Life care must reflect patient wishes, values
While reading the story I found it difficult to figure out whether feeding tubes are supposed to be beneficial to the patient or not. We already know that they make things easier for the staff at facilities. The only real effort staff has to put into the use of feeding tubes is to keep them from becoming occluded. I think it is better to use them than to let people who have forgotten how to eat waste away from starvation. That is a difficult way to go.
With dementia, they forget how to swallow, and can aspirate. G-tubes have an increased risk of aspiration, also. I believe hospitals 'forget' this at times.
Yes, it is easier, but is it helping in the long run, or extending the dying process?
Re: Study: End-of-Life care must reflect patient wishes, values
I think it is only extending the dying process. And there must be some economic advantage here. Much of health care is dollar driven so there has to be a money reason that underlies the practice.
There is a PESI seminar out there that covers the eatting bit. The whole seminar was awesome.
Honestly, our profession, as a whole, is driven to save lives. However, don't we all die someday?
Re: Study: End-of-Life care must reflect patient wishes, values
You have a point there. They should change their focus to making people comfortable. Feeding tube isn't necessarily comfortable.Originally Posted by cougarnurse
I am sure it isn't comfortable. And if someone is demented, they will try to pull it out; they know it isn't 'normal'.
Re: Study: End-of-Life care must reflect patient wishes, values
Have to agree with you there. Almost every person in this situation at one time or another tries to pull them out. And kids can't keep their hands off them.
Now this story from the NYTimes: Vital Signs - Hospital Type May Play a Role in Decision on Feeding Tubes - NYTimes.com
When nursing home residents with advanced dementia are sent to the hospital, many are given feeding tubes, even though the practice is not believed to help them live longer. Now a new study finds that it is much more prevalent at some hospitals than others.
The study, in the Feb. 10 issue of The Journal of the American Medical Association, analyzed more than a quarter of a million admissions of nursing home residents to thousands of hospitals from 2000 to 2007.
Some hospitals inserted feeding tubes in as few as one of every 100 patients with advanced dementia, others in as many as one of three.
Large hospitals and for-profit hospitals were more likely than others to insert the tubes, as were hospitals deemed aggressive about providing end-of-life care.
The findings suggest that such decisions are more likely to be based on hospital practices than on the wishes of patients and their families, said the lead author, Dr. Joan M. Teno, a professor of community health at the Warren Alpert School of Medicine of Brown University.
Of the wide variation in hospital practices, Dr. Teno said: “You have to ask, ‘Is there is a process in place for eliciting and respecting patient choice?’ We need to do a better job of informing family members to make a decision based either on what the patient’s previously stated wishes are, or what the family believes the loved one would want.”
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