251
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Sondas de alimentación en las demencias avanzadas: ¿mejoran algo? Semergen 2005. [DOI: 10.1016/s1138-3593(05)72888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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252
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Olson E, Cristian A. The role of rehabilitation medicine and palliative care in the treatment of patients with end-stage disease. Phys Med Rehabil Clin N Am 2005; 16:285-305, xi. [PMID: 15561556 DOI: 10.1016/j.pmr.2004.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Rehabilitation medicine and palliative care share many common goals. They strive to maximize physical function and emotional well-being to the highest extent possible given the nature of the underlying disease process. Many patients with end-stage disease experience symptoms and functional losses that diminish their quality of life. This article outlines the benefits that active rehabilitation therapy can provide to patients in the terminal stages of their disease and some of the ethical and practical issues faced in the planning and provision of this care.
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Affiliation(s)
- Ellen Olson
- Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, 130 West Kingsbridge Road, Routing number 00EX, Bronx, NY 10468, USA.
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253
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Bellelli G, Frisoni GB, Trabucchi M. Feeding tube use in Italian nursing homes: The role of cultural factors. J Am Med Dir Assoc 2005; 6:87-8. [PMID: 15871880 DOI: 10.1016/j.jamda.2004.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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254
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Caltagirone C, Bianchetti A, Di Luca M, Mecocci P, Padovani A, Pirfo E, Scapicchio P, Senin U, Trabucchi M, Musicco M. Guidelines for the Treatment of Alzheimer??s Disease from the Italian Association of Psychogeriatrics. Drugs Aging 2005; 22 Suppl 1:1-26. [PMID: 16506439 DOI: 10.2165/00002512-200522001-00002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A committee of experts from the Italian Association of Psychogeriatrics compiled the following report, which was then approved by a Steering Committee (comprising 20 specialists in neurology, psychiatry or geriatrics) from the Association and by two Alzheimer associations representing patients and families: the Italian Association for Alzheimer's Disease and the Italian Federation for Alzheimer's Disease. The report is based on a comprehensive review of the scientific literature on the treatment of Alzheimer's disease, discusses methodological aspects of dementia management, and details the limitations of current therapies. These guidelines are, in general, consistent with the principles of evidence-based medicine; however, for some controversial or poorly investigated issues, the guidelines integrate scientific evidence with experience and opinions from experts working in the clinical setting. In particular, the clinical experience of experts has been used to define recommendations for starting and interrupting pharmacotherapy, and to critically review evidence about the efficacy of non-pharmacological interventions. The principal pharmacotherapeutic interventions covered in the guidelines are acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine, and tacrine) and memantine. The main non-pharmacological interventions reviewed are memory training, reality orientation therapy, and combined non-pharmacological interventions. Other issues covered are opportunities for Alzheimer's disease prevention, various modalities of care, and the treatment of comorbidities.
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255
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Morgenstern L, Laquer M, Treyzon L. Ethical challenges of percutaneous endoscopic gastrostomy. Surg Endosc 2004; 19:398-400. [PMID: 15624065 DOI: 10.1007/s00464-004-8109-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2004] [Accepted: 07/08/2004] [Indexed: 01/24/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients who cannot swallow. Although it is mostly performed for valid indications, its use in terminally ill patients is questionable. In this study, more than 30% of patients died in hospital after PEG placement and 16% died less than 30 days after placement. Strict guidelines and oversight or PEG placement are recommended.
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Affiliation(s)
- L Morgenstern
- Center for Health Care Ethics, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
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256
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Pasman HRW, Onwuteaka-Philipsen BD, Ooms ME, van Wigcheren PT, van der Wal G, Ribbe MW. Forgoing artificial nutrition and hydration in nursing home patients with dementia: patients, decision making, and participants. Alzheimer Dis Assoc Disord 2004; 18:154-62. [PMID: 15494621 DOI: 10.1097/01.wad.0000137522.69111.56] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the characteristics of patients for whom it is decided to forgo artificial nutrition and hydration (ANH) and characteristics of the ANH decision-making process. We conducted an observational study with the use of written questionnaires. For 178 nursing home patients with dementia, the treating nursing home physician (NHP), a family member, and a nurse filled out a questionnaire directly after the decision was made to forgo ANH. RESULTS We found that most patients had severe dementia and two thirds had an acute illness. Advance care planning had taken place in 68% of the cases. In two thirds of the cases, the primary aim in forgoing ANH was to avoid unnecessary prolongation of life; and nurses seemed to have less influence on the decision-making process than NHPs and family members. Almost all respondents evaluated the decision-making process as "good" or "adequate." Dissatisfaction was felt when the decision had to be made under the pressure of time constraint. CONCLUSIONS On the basis of these results, we recommend that discussions that include NHPs, family members, and nurses concerning decisions about possible future situations be held on a regular basis. This will form the basis for the difficult ANH decision and will probably reduce the pressure of time constraint.
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Affiliation(s)
- H Roeline W Pasman
- Department of Public, Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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257
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Jotkowitz A. Feeding Patients with Advanced Dementia: A Jewish Ethical Perspective. THE JOURNAL OF CLINICAL ETHICS 2004. [DOI: 10.1086/jce200415412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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258
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Ashby MA, Mendelson D. Gardner; re BWV: Victorian Supreme Court makes landmark Australian ruling on tube feeding. Med J Aust 2004; 181:442-5. [PMID: 15487963 DOI: 10.5694/j.1326-5377.2004.tb06371.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2004] [Accepted: 06/22/2004] [Indexed: 11/17/2022]
Abstract
The Victorian Supreme Court has decided that artificial nutrition and hydration provided through a percutaneous gastrostomy tube to a woman in a persistent vegetative state may be withdrawn. The judge ruled, in line with a substantial body of international medical, ethical and legal opinion, that any form of artificial nutrition and hydration is a medical procedure, not part of palliative care, and that it is a procedure to sustain life, not to manage the dying process. Thus, the law does not impose a rigid obligation to administer artificial nutrition or hydration to people who are dying, without due regard to their clinical condition. The definition of key terms such as "medical treatment", "palliative care", and "reasonable provision of food and water" in this case will serve as guidance for end-of-life decisions in other states and territories. The case also reiterates the right of patients, and, when incompetent, their validly appointed agents or guardians, to refuse medical treatment. Where an incompetent patient has not executed a binding advance directive and no agent or guardian has been appointed, physicians, in consultation with the family, may decide to withdraw medical treatment, including artificial nutrition or hydration, on the basis that continuation of treatment is inappropriate and not in the patient's best interests. However, Victoria and other jurisdictions would benefit from clarification of this area of the law.
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Affiliation(s)
- Michael A Ashby
- Palliative Care Unit, McCulloch House, Monash Medical Centre, 246 Clayton Rd, Clayton, VIC 3168, Australia.
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259
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Abstract
While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population.
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Affiliation(s)
- Greg A Sachs
- Department of Medicine, Section of Geriatrics, The University of Chicago, Chicago, IL, USA
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260
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Shintani S, Shiigai T. Survival-determining factors in patients with neurologic impairments who received home health care in Japan. J Neurol Sci 2004; 225:117-23. [PMID: 15465094 DOI: 10.1016/j.jns.2004.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2003] [Revised: 03/09/2004] [Accepted: 07/12/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Japanese have become the longest-lived nation population in the world, and numbers of elderly who require medical and nursing care are increasing. The capacity of nursing homes and nursing institutions is sharply limited in Japan; further, as a group, elderly Japanese patients prefer home care to institutional care. For these reasons, the home health care system in Japan has been increasingly important. OBJECTIVE We sought to identify factors determining long-term survival in Japanese patients receiving home health care for neurologic disorders. PATIENTS AND METHODS We retrospectively evaluated 180 patients with neurologic disease, who received home health care conducted by our hospital between 1992 and 2001. Factors considered were age; gender; illnesses; prognosis; follow-up period; activities of daily living (ADL); behavioral, cognitive, and communicative functions; swallowing function; feeding method; serum nutritional values (total protein, albumin, and total cholesterol); hemoglobin concentration; and social care services provided at home. RESULTS Variables affecting long-term survival in 180 patients with neurologic disease were age (P<0.0002) and severity of dysphagia (P<0.04) by Cox's proportional hazard test. CONCLUSION Maintenance of swallowing function and adequate nutrition through a variety of feeding methods that can be provided by a home health care program are important for long-term survival of patients with stroke and also that of patients with other neurologic diseases.
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Affiliation(s)
- Shuzo Shintani
- Department of Neurology, Toride Kyodo General Hospital, 2-1-1 Hongoh, Toride City, Ibaraki 302-0022, Japan.
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261
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Aspekte der k�nstlichen Ern�hrung bei demenzkranken Patienten in der Geriatrie. Ethik Med 2004. [DOI: 10.1007/s00481-004-0318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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262
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Nutzen und Grenzen der Sondenern�hrung am Lebensende. Ethik Med 2004. [DOI: 10.1007/s00481-004-0321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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263
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Eggenberger SK, Nelms TP. Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making. J Clin Nurs 2004; 13:661-7. [PMID: 15317505 DOI: 10.1111/j.1365-2702.2004.00967.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND As Alzheimer's disease progresses to its final stages of dementia and dysphagia, whereby patients can no longer swallow food and fluids, families suffer with difficult decisions regarding initiation of artificial hydration and nutrition. AIMS AND OBJECTIVES Through the use of a hypothetical family scenario, this theoretical article presents the ethical principals of beneficence and autonomy as a framework for use by nurses to hear and inform family decision-makers of the physiology of death in the advanced stages of Alzheimer's and examines the current literature related to benefits and burdens of artificial hydration and nutrition. CONCLUSIONS While a beneficial consideration, ethical principles are critiqued for their inability to provide an absolute answer and relieve family suffering in this clinical situation. RELEVANCE TO CLINICAL PRACTICE A nurse-lead consensus building process is proposed to guide family decision-making regarding artificial hydration and nutrition with advanced Alzheimer's disease.
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264
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Pasman HW, The BM, Onwuteaka-Philipsen BD, Ribbe MW, van der Wal G. Participants in the decision making on artificial nutrition and hydration to demented nursing home patients: A qualitative study. J Aging Stud 2004. [DOI: 10.1016/j.jaging.2004.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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265
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Abstract
While Judaism espouses the infinite value of human life, Judaism recognizes that all life is finite and, as such, its teachings are compatible with the principles of palliative medicine and end-of-life care as they are currently practiced. Jewish medical ethics as derived from Jewish law, has definitions for the four cardinal values of secular medical ethics: autonomy, beneficence, nonmaleficence, and justice, with the major difference between Jewish law and secular medical ethics being that orthodox or traditional Jews are perceived to limit their autonomy by choosing, with the assistance and advice of their rabbis, to follow God's law as defined by the Bible and post-Biblical sources. With an understanding of Jewish medical ethics as defined by Jewish law, various issues pertaining to the care of Jewish patients who are near the end-of-life can be better understood. Jewish tradition contains within its textual sources the concept of terminal illness. The shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden. For patients who are terminally ill, treatments that are not potentially curative may be refused, especially when harm may result. Under certain circumstances, treatments may be withheld, but active treatment already started may not usually be withdrawn. While patients should generally not be lied to regarding their conditions, withholding information or even providing false information may be appropriate when it is felt that the truth will cause significant harm. Pain and suffering must be treated aggressively, even if there is an indirect risk of unintentionally shortening life. Finally, patients may execute advance directives, providing that the patient's rabbi is involved in the process.
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266
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Shega JW, Hougham GW, Cox-Hayley D, Sachs GA, Stocking CB. Advanced Dementia and Feeding Tubes: Do Physician Factors Contribute to State Variation? J Am Geriatr Soc 2004; 52:1217-8. [PMID: 15209668 DOI: 10.1111/j.1532-5415.2004.52327_2.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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267
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Basta LL. Ethical issues in the management of geriatric cardiac patients. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2004; 13:168-70. [PMID: 15133420 DOI: 10.1111/j.1076-7460.2004.02707.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- L L Basta
- The University of South Florida, Tampa, FL, USA
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268
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269
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Abstract
Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.
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Affiliation(s)
- Elizabeth Goy
- Portland Veterans Affairs Medical Center, Mental Health, P3MHDC, P.O. Box 1034, Portland, OR 97207, USA.
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270
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Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-Feeding Versus Hand-Feeding Nursing Home Residents with Advanced Dementia: A Cost Comparison. J Am Med Dir Assoc 2004. [DOI: 10.1016/s1525-8610(04)70086-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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271
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Aupperle PM, MacPhee ER, Strozeski JE, Finn M, Heath JM. Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist. Am J Alzheimers Dis Other Demen 2004; 19:94-104. [PMID: 15106390 PMCID: PMC10833951 DOI: 10.1177/153331750401900204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.
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Affiliation(s)
- Peter M Aupperle
- Division of Geriatric Psychiatry, Department of Psychiatry, University Behavioral Healthcare, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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272
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Abstract
For much of the late 20th century, feeding tubes were often considered essential in the treatment of people with advanced Alzheimer's disease (AD) who developed swallowing or eating problems. Increasingly, the use of feeding tubes (i.e., percutaneous endoscopic gastrostomy or PEG tubes), has been challenged by empirical research, which has not supported the rationales provided for this intervention. The purpose of this commentary is to explain why healthcare providers, in light of empirical evidence, should refrain from using the terms "life-sustaining" or "life-prolonging" when discussing tube feeding with older adults, their family members, or other surrogate decision-makers.
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Affiliation(s)
- Debra Lacey
- School of Social Work, Florida Atlantic University, Fort Lauderdale, Florida, USA
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273
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Miller FG. End-of-life care for patients with dementia. N Engl J Med 2004; 350:733-4; author reply 733-4. [PMID: 14960754 DOI: 10.1056/nejm200402123500721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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274
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Lubart E, Leibovitz A, Habot B. Attitudes of relatives and nursing staff toward tuboenteral feeding in severely demented patients. Am J Alzheimers Dis Other Demen 2004; 19:31-4. [PMID: 15002342 PMCID: PMC10833675 DOI: 10.1177/153331750401900107] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Elderly patients with advanced dementia present a challenge with respect to efficient nutrition and hydration because of oropharyngeal dysphagia and lack of patient cooperation. For increasing numbers of patients, long-term tuboenteral feeding (TEF) is an alternative for providing food and fluids, with the hope of reducing the risk of aspiration. The purpose of this study is to learn about the opinions and the attitudes of relatives and nursing staff regarding patients on TEF for at least one year. The study included all the demented patients on TEF in four skilled nursing facilities and four nursing wards. Researchers retrieved clinical data from patients' medical records and prepared a questionnaire to survey the opinions of relatives and staff members. The study included 111 patients: 89 on nasogastric tube (NGT) feeding and 22 on percutaneous endoscopic gastrostomy (PEG) feeding. The clinical condition of both groups was satisfactory, as reflected by albumin, hemoglobin, and Body Mass Index (BMI). Relatives of the demented patients as well as the staff members were ambivalent toward TEF. Although most of them called it an essential procedure for delivering food and fluids for life support, about the same number expressed concerns that TEF prolonged a life of suffering. Nevertheless, most relatives and staff members were resistant to the idea of withholding TEF. The data show that TEF does provide efficient nutrition and hydration to patients with advanced dementia, and it is used in accordance with the will of the relatives. Any change in the present approach regarding TEF in these patients should be preceded by discussions with their relatives.
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Affiliation(s)
- Emilia Lubart
- Shmuel Harofe Hospital, Geriatric Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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275
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Detweiler MB, Kim KY, Bass J. Percutaneous endoscopic gastrostomy in cognitively impaired older adults: a geropsychiatric perspective. Am J Alzheimers Dis Other Demen 2004; 19:24-30. [PMID: 15002341 PMCID: PMC10833934 DOI: 10.1177/153331750401900105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.
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Affiliation(s)
- Mark B Detweiler
- Salem Veterans Affairs Medical Center, Edward Via Virginia College of Osteopathic Medicine, University of Virginia, Virginia, USA
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276
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Shega JW, Hougham GW, Stocking CB, Cox-Hayley D, Sachs GA. Barriers to Limiting the Practice of Feeding Tube Placement in Advanced Dementia. J Palliat Med 2003; 6:885-93. [PMID: 14733680 DOI: 10.1089/109662103322654767] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE In advanced dementia, many difficult decisions may arise as the disease progresses, including whether to use feeding by tube. Several recent articles question the benefit of percutaneous endoscopic gastrostomy (PEG) tube placement in persons with advanced dementia. However, patients with advanced dementia are still referred for PEG tubes. This study attempts to understand more about physician decisions to recommend PEG tube placement in patients with advanced dementia. DESIGN Mailed survey. SETTING Random sample of 500 physicians from the American Medical Association Masterfile. PARTICIPANTS Primary care physicians. MEASUREMENTS Physician knowledge, beliefs, and self-reported practices of PEG tubes in advanced dementia. RESULTS Of the 416 eligible participants, 195 completed surveys (response rate of 46.9%). A significant number of physicians believe PEG tubes have the following benefits in advanced dementia: reduce aspiration pneumonia (76.4%), and improve pressure ulcer healing (74.6%), survival (61.4%), nutritional status (93.7%), and functional status (27.1%). Most physicians underestimate 30-day mortality in patients who receive a PEG and more than half of physicians believe PEG tubes in advanced dementia are the standard of care. Also, a majority of physicians believe speech therapists, nurses, and nutritional support teams recommend feeding tubes, which influences their decision to recommend a PEG. Last, almost half of these respondents had a nursing home request PEG tube placement, leading physicians to recommend a PEG. CONCLUSIONS We find a notable discord between physician opinion, reported practice, and the literature regarding PEG tubes in advanced dementia that reveals some of the barriers to decreasing the referral of these patients for PEG.
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Affiliation(s)
- Joseph W Shega
- Department of Medicine, Section of Geriatrics, The University of Chicago, Chicago, Illinois 60637, USA.
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277
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278
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279
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Low JA, Chan DKY, Hung WT, Chye R. Treatment of recurrent aspiration pneumonia in end-stage dementia: preferences and choices of a group of elderly nursing home residents. Intern Med J 2003; 33:345-9. [PMID: 12895164 DOI: 10.1046/j.1445-5994.2003.00367.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinicians are often faced with the dilemma of how best to manage patients with advanced dementia who present to the hospital with repeated episodes of aspiration pneumonia. Rarely, if at all, are the opinions of the group that is most likely to be directly affected, that is the older nursing home resident, sought. This study seeks to fill that gap. AIMS To study the choices and preferences of a group of elderly nursing home residents in the treatment of recurrent aspiration pneumonia on a background of severe disability from end-stage dementia. METHODS A descriptive cross-sectional interview study using a hypothetical scenario carried out in six nursing homes within eastern Sydney, from June to August 2000. Views and attitudes towards hospitalization, antibiotic use, tube feeding and other treatment measures, given a situation of recurrent aspiration pneumonia and end-stage dementia, were obtained. RESULTS Fifty-two elderly nursing home residents who were cognitively intact and not depressed were interviewed. Most of the subjects would prefer further hospital admissions (61.5%, P<0.1) and would choose to have antibiotic treatment (73.1%, P<0.001). Slightly more than half would not agree to artificial ventilation. Sixty-nine percent of the respondents would not agree to feeding via a nasogastric tube (P<0.05) and 71% would not agree to a feeding gastrostomy (P<0.001). Most would agree to a modified diet (75%, P<0.0001) and to continue oral feeding despite the attendant risk of re-aspiration (59.6%, P<0.01). CONCLUSIONS The participants generally preferred to be treated in a hospital setting given the scenario. Most disagreed with the use of artificial feeding.
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Affiliation(s)
- J A Low
- Department of Geriatrics, Alexandra Hospital, Singapore.
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280
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Fortunat S, Röggla G. [Percutaneous endoscopic gastrostomy in demented patients]. Wien Klin Wochenschr 2003; 115:438. [PMID: 12918189 DOI: 10.1007/bf03040438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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281
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LeGrand SB, Walsh D, Nelson KA, Davis MP. A syllabus for fellowship education in palliative medicine. Am J Hosp Palliat Care 2003; 20:279-89. [PMID: 12911073 DOI: 10.1177/104990910302000410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.
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Affiliation(s)
- Susan B LeGrand
- Palliative Medicine Fellowship Program, The Harry R. Horvitz Center for Palliative Medicine, The Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
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282
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Loeser C, von Herz U, Küchler T, Rzehak P, Müller MJ. Quality of life and nutritional state in patients on home enteral tube feeding. Nutrition 2003; 19:605-11. [PMID: 12831946 DOI: 10.1016/s0899-9007(02)01072-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE We assessed quality of life (QOL) in patients on home enteral tube feeding (HETF). The data should contribute to ethically justified decision making. METHODS We used a prospective cross-sectional study (study 1) in 155 consecutive patients and a prospective longitudinal study (study 2) with a follow-up of 4 mo in 56 patients. QOL was assessed by proxy rating (Karnofsky and Spitzer indices) and self-rating (European Organization for Research and Treatment of Cancer [EORTC] QLQ C30) extended by a specific module. RESULTS In study 1, weight losses 3 mo before HETF were 10.5 +/- 8.4% and 7.9 +/- 6.3% in competent (P < 0.05) and non-competent (P < 0,05) patients, respectively. The prevalences of severe malnutrition and weight loss were 50% and 73%, respectively. When compared with EORTC reference data for a general population, QOL was lower in HETF patients. The lowest QOL was seen in non-competent patients. Nutrition status explained up to 13% of the variance in QOL. In study 2, nutrition status stabilized or increased slightly in response to HETF. This was true for competent and non-competent patients and for patients with malignant and benign diseases. Concomitantly, physical functioning improved, whereas fatigue decreased. QOL increased in response to HETF in competent and non-competent patients, and 50% of the non-competent patients became competent CONCLUSIONS . Measures of QOL research can be used in HETF patients. QOL is reduced in patients on HETF. Part of this effect is explained by malnutrition. HETF can prevent further weight loss and improve some aspects of QOL, thus allowing physicians to focus on patients.
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Affiliation(s)
- Christian Loeser
- 1st Medical Department, the Institute of Human Nutrition and Food Science, Reference Center of Quality of Life in Oncology, Christian-Albrechts-University of Kiel, Kiel, Germany
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Abstract
Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion.
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Affiliation(s)
- Yaron Niv
- Department of Gastroenterology, Rabin Medical Center, Beilinson Campus, Tel Aviv University, Petach Tikva, Israel.
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285
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Degenholtz HB, Thomas SB, Miller MJ. Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med 2003; 31:S373-8. [PMID: 12771586 DOI: 10.1097/01.ccm.0000065121.62144.0d] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Howard B Degenholtz
- Center for Bioethics and Health Law, and Department of Health Policy and Management, University of Pittsburgh, PA 15213, USA
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286
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Mion LC, O'Connell A. Parenteral hydration and nutrition in the geriatric patient: clinical and ethical issues. JOURNAL OF INFUSION NURSING 2003; 26:144-52. [PMID: 12792372 DOI: 10.1097/00129804-200305000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A common ethical and legal issue in elder care involves the decision to withhold or withdraw parenteral hydration and nutrition (PHN) at the end of life and in the terminal stage of dementia. The aging of the population will impact the frequency with which nurses face this situation in their practices and with their families. The ethical, legal, and clinical issues involving PHN discussed in this article will assist the nurse in his or her practice.
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Affiliation(s)
- Lorraine C Mion
- Division of Nursing, The Cleveland Clinic Foundation, OH 44195, USA.
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287
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Affiliation(s)
- George T Grossberg
- Department of Psychiatry, Division of Geriatric Psychiatry, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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288
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Abstract
OBJECTIVE Offering and recommending PEG tube placement to patients has been a topic of considerable interest in the medical literature. The role of individual health care professionals in the decision making process is poorly defined. PEG tubes are often placed inappropriately because of unrealistic and inaccurate expectations of what they can accomplish in patients unable to tolerate adequate oral intake. We have developed an algorithm for PEG placement for the geriatric, oncology, and neurology patients based on a critical review of current literature. METHODS An extensive review of the literature was performed focusing on PEG tube placement in oncology, neurology, and geriatric patients. This algorithm was developed to provide both the primary care provider and the specialist with appropriate indications for PEG placement in these patient populations. RESULTS Appropriate indications for PEG placement are 1) Esophageal obstruction (e.g., esophageal cancer), 2) Neurologic etiology of dysphagia without obstruction (e.g., status post cerebrovascular accident, pseudobulbar palsy), 3) Prolonged refusal to swallow without evidence of concomitant terminal illness (e.g., protracted pseudodementia due to severe depression), 4) Supplemental nutrition for patients undergoing chemotherapy or radiation therapy. CONCLUSIONS If no physiologic benefit is expected with PEG placement (anorexia-cachexia syndrome), the health care team has no obligation to offer or perform an intervention. This same principle would apply if intervention improves physiologic states but has no effect on quality of life (e.g., permanent vegetative state). Small-bore feeding tubes are cost effective and relatively safe for enteral feedings of up to 6-8 weeks. This is especially pertinent in the population with acute neurological deficits, in which prognostication on extent of impairment is best estimated by communication with neurologist. In the geriatric population there is no proved benefit in weight gain or markers of nutrition (albumin, prealbumin) in patients with malnutrition due to impaired oral intake.
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Affiliation(s)
- Floyd Angus
- Department of Gastroenterology, Washington Hospital Center, D.C. 20010, USA
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289
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Md SLM, Mph DKK, Gillick MR. Nursing Home Characteristics Associated with Tube Feeding in Advanced Cognitive Impairment. J Am Geriatr Soc 2003. [DOI: 10.1034/j.1601-5215.2002.51013.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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290
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Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. J Am Med Dir Assoc 2003; 5:S22-9. [PMID: 14984607 DOI: 10.1097/01.jam.0000043421.46230.0e] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN Retrospective cohort study. SETTING A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. MEASUREMENTS Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.
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Affiliation(s)
- Susan L Mitchell
- Hebrew Rehabilitation Center for Aged Research and Training Institute, Department of Medicine of Beth Israel Deaconess Medical Center, Division on Aging, Harvard Medical School, Boston, MA 02131, USA.
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291
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Leibovitz A, Plotnikov G, Habot B, Rosenberg M, Segal R. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med Sci 2003; 58:52-5. [PMID: 12560411 DOI: 10.1093/gerona/58.1.m52] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aspiration of infected oropharyngeal content is the main cause of aspiration pneumonia. This complication, mainly related to gram-negative bacteria, threatens percutaneous enterogastric tube as well as nasogastric tube (NGT) fed patients. The objective of this study was to examine the oral microbiota of tuboenterally fed patients and compare it with that of orally fed counterparts. METHODS Patients were recruited for this study from six nursing and skilled nursing facilities with an overall number of 845 beds. Enrolled were 215 patients: Group 1 consisted of 78 patients on NGT feeding, Group 2 consisted of 57 patients on percutaneous enterogastric tube feeding, and Group 3 consisted of 80 patients fed orally who were from the same facilities. Cultures were performed by sampling the oropharynx of each subject in order to identify gram-negative bacteria and Staphylococcus aureus. RESULTS A high prevalence of potentially pathogenic isolations was found in tuboenterally fed patients: 81% in Group 1 and 51% in Group 2, as compared with only 17.5% in Group 3 (p <.0001). Pseudomonas aeruginosa was cultured from 31% of the subjects in Group 1 and 10% of Group 2, but in none of Group 3 (p <.001). Klebsiella and Proteus were isolated mainly from the NGT fed patients (p <.003). No correlation was found between the time duration on tube feeding or the presence of residual dentition and pathogenic microbiota. CONCLUSION This study shows that tuboenteral feeding in elderly patients is associated with pathogenic colonization of the oropharynx. These findings are related to the risk of aspiration pneumonia and are compelling for the reevaluation of current oral cleansing procedures.
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Affiliation(s)
- Arthur Leibovitz
- Shmuel Harofe Hospital (affiliated with the Sackler Faculty of Medicine), Geriatric Medical Center, Beer-Yaakov, Israel
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292
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Enteral Nutrition Support in Elderly Residents of Long-Term Care Facilities. TOP CLIN NUTR 2003. [DOI: 10.1097/00008486-200301000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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293
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Mitchell SL. Financial Incentives for Placing Feeding Tubes in Nursing Home Residents with Advanced Dementia. J Am Geriatr Soc 2003. [DOI: 10.1034/j.1601-5215.2002.51021.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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294
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Valero Zanuy M, Moreno Villares J, León Sanz M, Álvarez Nido R, de Diego Muñoz R. ¿Se debe limitar el esfuerzo terapéutico en nutrición artificial? Rev Clin Esp 2003. [DOI: 10.1016/s0014-2565(03)71363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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295
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The AM, Pasman R, Onwuteaka-Philipsen B, Ribbe M, van der Wal G. Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study. BMJ 2002; 325:1326. [PMID: 12468479 PMCID: PMC137804 DOI: 10.1136/bmj.325.7376.1326] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2002] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes. DESIGN Qualitative, ethnographic study in two phases. SETTING 10 wards in two nursing homes in the Netherlands. PARTICIPANTS 35 patients with dementia, eight doctors, 43 nurses, and 32 families. RESULTS The clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients' quality of life by their care providers were considered more important than living wills and policy agreements. CONCLUSIONS Doctors' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient's medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family.
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Affiliation(s)
- Anne-Mei The
- Department of Social Medicine, Institute for Research in Extramural Medicine, Vrije University Medical Centre, 1081 BT, Amsterdam, Netherlands.
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296
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Abstract
The use of tube feeding in some patients can be controversial, however, few studies have investigated dietitians' opinions on this subject. A cross-sectional survey of 345 members the Irish Nutrition and Dietetic Institute was conducted using a self-administered, anonymous, postal questionnaire. A 44% response rate was achieved. Mean number of years qualified was 9.3 (8.4). Eighty-one per cent of responders were involved in initiating tube feeding in stroke patients, and 8.5% in discontinuing tube feeding in a patient in a persistent vegetative state (PVS). Nine per cent felt that their input had no influence on the care plan of the patient with dementia and 67% felt that the information given to families (or other decision makers) concerning tube feeding was inadequate. The majority of respondents favoured tube feeding fictitious stroke and cancer patients, but less than half favoured tube feeding a fictitious patient in a PVS or a patient with dementia. When given similar scenarios involving themselves, fewer dietitians wanted to be tube fed.
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Affiliation(s)
- S Healy
- School of Biological Sciences, Dublin Institute of Technology, Kevin Street, Dublin 7, Republic of Ireland
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297
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Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis 2002; 35:1205-11. [PMID: 12410480 DOI: 10.1086/344281] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2002] [Accepted: 08/06/2002] [Indexed: 11/03/2022] Open
Abstract
Pneumonia is the most serious of the common infections that occur in nursing homes, with a high case-fatality rate and considerable mortality among survivors. Risk factors for nursing home-acquired pneumonia (NHAP) have been defined, and prediction models for death due to NHAP have been developed. The bacterial etiology of NHAP has been debated, but "typical" bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) are most important. Clinical presentation of NHAP is said to be "atypical," but this may be confounded by dementia in the nursing home resident. A recent guideline has made recommendations regarding the minimal diagnostic workup when a resident has a suspected case of pneumonia. Until recently, most guidelines for the treatment of pneumonia did not specifically address NHAP; there is some evidence that use of a quinolone alone may be an acceptable first choice of therapy for most cases. Pneumococcal and influenza vaccination have been the primary prevention measures. However, additional methods to prevent NHAP should be evaluated, including improving the oral hygiene of residents and instituting pharmacological interventions.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, Division of Infectious Diseases, School of Medicine and Biomedical Sciences, University at Buffalo, Erie County Medical Center, Buffalo, New York 14215, USA.
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298
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Fox MR, Harris AW. An assessment of open access referral for percutaneous endoscopic gastrostomy in a district general hospital. Eur J Gastroenterol Hepatol 2002; 14:1245-9. [PMID: 12439120 DOI: 10.1097/00042737-200211000-00013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the indications, technical success and outcomes of open access percutaneous endoscopic gastrostomy (PEG) insertion in the district general hospital setting. DESIGN This study was a retrospective audit of patients receiving PEG by the thread pull method from November 1998 to November 1999, followed by a prospective audit of patients receiving PEG from December 1999 to May 2000. Prophylactic antibiotics were not used. Patient data were collected using a computerized endoscopy unit record system. Clinical assessment was performed and case notes were reviewed. Whenever necessary, telephone follow-up of patients in the community was performed. PARTICIPANTS Sixty-five consecutive, unselected patients underwent PEG and 64 were followed up for a total of 7799 patient days. Fifty-seven of 64 (89%) were in-patients. The median age of the patients was 74 years (range, 26-95 years). MAIN OUTCOME MEASURES Indications, technical success, early complications and long-term outcomes of PEG. RESULTS Cerebrovascular disease was the most common indication for PEG (35/64 (55%)). Technical success was achieved in 62/64 (97%) patients. No serious complications from the procedure were reported: PEG site infection was rare (1/64). Pneumonia was uncommon (8/64 (12.5%)). There were eight (12.5%) deaths during the first week after PEG insertion and 18/64 (28%) during the first month. Mortality at 1 year was 36/64 (56%). Ten of 64 patients (16%) recovered to PEG removal; 18 (28%) continue to be fed via PEG. CONCLUSION This audit demonstrates that referral patterns, technical success and long-term outcome of open access referral for PEG in a district general hospital setting are consistent with published series from specialist and tertiary referral centres.
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Affiliation(s)
- Mark R Fox
- Kent & Sussex Hospital, Tunbridge Wells TN4 8AT, UK.
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299
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Berkovitch M, Dafni O, Leiboviz A, Mayan H, Habut B, Segal R. Therapeutic drug monitoring of theophylline in frail elderly patients: oral compared with nasogastric tube administration. Ther Drug Monit 2002; 24:594-7. [PMID: 12352930 DOI: 10.1097/00007691-200210000-00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Treating debilitated elderly patients through nasogastric tube (NGT) can change the pharmacokinetic characteristics of drugs, mainly those that are slow released (SR). The purpose of this study was to compare pharmacokinetic parameters between patients who receive SR theophylline orally and those who receive it through NGT. PATIENTS AND METHODS The authors studied elderly patients in the geriatric ward receiving SR theophylline for chronic obstructive lung disease. In 17 patients fed by NGT (group I), theophylline was removed from the capsule and mixed with 10 mL of water. Group II included 15 patients who swallowed the drug orally. Theophylline blood levels were measured, as were peak concentration (C(max) ), time to peak (T(max) ), and area under the serum concentration-time curves (AUC). RESULTS The mean daily dose was not statistically different between the two groups: 320 +/- 130 (200-500) mg/d in group I and 360 +/- 85 (200-500) mg/d in group II, given twice daily. All pharmacokinetic measurements were lower in group I as compared with group II: trough theophylline blood levels were 3.78 +/- 3.2 (0.5-10.77) microg/mL versus 8.63 +/- 4.6 (0-15.61) microg/mL ( P= 0.002); C(max) was 6.53 +/- 4.1 (1.3-13.33) microg/mL versus 10.51 +/- 3.30 (4.3-16.28) microg/mL (P = 0.0058), and AUC was 50.04 +/- 38.59 (11-112) microg/h/mL versus 80.37 +/- 28.8 (23-148) microg/h/ml (P = 0.024). CONCLUSIONS Patients receiving the drug through NGT had variability and unexpectedly low blood levels. Therefore, the pharmacokinetic parameters of SR preparations should be evaluated before their administration through NGT.
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300
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Abstract
With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person's values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers. At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs. The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.
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Affiliation(s)
- Michael Gordon
- Geriatrics and Internal Medicine, Baycrest Centre for Geriatric Care, University of Toronto, 3560 Bathurst Street, Toronto, Ontario M6A 2E1, Canada
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