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Shapiro AB, Smith MA, Moshe CT, Frey GT, Chadha RM. Remimazolam As a Sole Sedative Agent for Gastrostomy Tubes Placed in the Interventional Radiology Suite: A Case Series. A A Pract 2024; 18:e01839. [PMID: 39105528 DOI: 10.1213/xaa.0000000000001839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.
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Affiliation(s)
- Anna Bovill Shapiro
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Michael A Smith
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Christine T Moshe
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gregory T Frey
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Ryan M Chadha
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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Yuen JK, Chan FHW, Chan TC, Chow DTY, Chu STW, Shea YF, Luk JKH. Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia. J Nutr Health Aging 2023; 27:432-437. [PMID: 37357327 DOI: 10.1007/s12603-023-1926-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/08/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019. METHODS Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models. RESULTS Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63). CONCLUSIONS AND IMPLICATIONS A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.
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Affiliation(s)
- J K Yuen
- Jacqueline K. Yuen, MD, Division of Geriatrics, LKS Faculty of Medicine, The University of Hong Kong, Department of Medicine, 4/F Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China. E-mail: Telephone: (852) 2255-4049
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Yuen JK, Luk JKH, Chan TC, Shea YF, Chu ST, Bernacki R, Chow DTY, Chan FHW. Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding. J Am Med Dir Assoc 2022; 23:1541-1547.e2. [PMID: 35489380 DOI: 10.1016/j.jamda.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019. METHODS Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models. RESULTS Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30). CONCLUSIONS AND IMPLICATIONS For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.
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Affiliation(s)
- Jacqueline K Yuen
- Division of Geriatrics, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - James K H Luk
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, Hong Kong SAR, China
| | - Tuen-Ching Chan
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, Hong Kong SAR, China
| | - Yat-Fung Shea
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, Hong Kong SAR, China
| | - Steven T Chu
- Division of Geriatrics, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David T Y Chow
- Department of Speech Therapy, TWGHs Fung Yiu King Hospital and Grantham Hospital, Hong Kong SAR, China
| | - Felix H W Chan
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, Hong Kong SAR, China
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Lodhia J, Suleiman J, Chipongo H, Shadrack M, Msuya D, Chilonga K. Modified gastrostomy feeding tubes in patients with oesophageal cancer: our experience from Northern Tanzania. J Surg Case Rep 2021; 2021:rjab221. [PMID: 34055301 PMCID: PMC8159268 DOI: 10.1093/jscr/rjab221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/14/2021] [Indexed: 01/16/2023] Open
Abstract
Surgeons in resource-limited settings have adapted to overcome the challenges of the limitations of resources using different available methods and inventions from the local environment. We report four cases of oesophageal cancer palliatively treated with improvised gastrostomy feeding tubes by using 24Fr urinary catheters, to optimize their nutritional status to withstand chemotherapy/radiotherapy. Two patients managed to begin chemo and radiotherapy, but only one out of the four survived. The aim of this report is to appraise the methods used by surgeons to overcome the challenges they face in clinical practice.
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Affiliation(s)
- Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jamil Suleiman
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Hillary Chipongo
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Mathayo Shadrack
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kondo Chilonga
- Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
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Manu ER, Fitzgerald JT, Mullan PB, Vitale CA. Eating Problems in Advanced Dementia: Navigating Difficult Conversations. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:11025. [PMID: 33241119 PMCID: PMC7678029 DOI: 10.15766/mep_2374-8265.11025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 07/02/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD. METHODS We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar. RESULTS Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant (p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7). DISCUSSION An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers.
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Affiliation(s)
- Erika R. Manu
- Assistant Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School; Physician, VA Ann Arbor Geriatric Research, Education and Clinical Center (GRECC)
| | - James T. Fitzgerald
- Professor Emeritus, Department of Learning Health Sciences, University of Michigan Medical School
| | - Patricia B. Mullan
- Professor Emerita, Department of Learning Health Sciences, University of Michigan Medical School
| | - Caroline A. Vitale
- Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School; Associate Director of Education and Evaluation, VA Ann Arbor Geriatric Research, Education and Clinical Center (GRECC)
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Loofs TS, Haubrick K. End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes. Am J Hosp Palliat Care 2020; 38:1028-1041. [PMID: 32945174 DOI: 10.1177/1049909120960124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs. METHODS A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21). RESULTS The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.
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Affiliation(s)
- Tyler S Loofs
- St. David's Georgetown Hospital, Georgetown, TX, USA
| | - Kevin Haubrick
- 165982The University of Houston College of Liberal Arts and Social Sciences, TX, USA
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Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits. J Aging Res 2019; 2019:7272067. [PMID: 31929906 PMCID: PMC6942829 DOI: 10.1155/2019/7272067] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/06/2019] [Indexed: 01/02/2023] Open
Abstract
Background Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society. Objective To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia. Design Narrative review. Methods Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia. Results Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review. Conclusion Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.
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Yamaguchi H, Sato K, Kawahito K, Miyatake A, Kondo K, Inaba K, Inaba K, Kawaminami S, Tabata R, Yuasa S, Okura Y, Tuchiya A, Suzuki Y, Tani K. Japanese elderly individuals wish for enteral tube feeding more strongly for their parents than for themselves. THE JOURNAL OF MEDICAL INVESTIGATION 2019; 66:258-263. [PMID: 31656285 DOI: 10.2152/jmi.66.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.
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Affiliation(s)
- Harutaka Yamaguchi
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Koj Sato
- Medical student, Tokushima University, Tokushima, Japan
| | | | | | | | - Keisuke Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kaori Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shingo Kawaminami
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Ryo Tabata
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shino Yuasa
- Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okura
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
| | - Atsushi Tuchiya
- Department of Civil and Environmental Studies, Tokushima University Graduate School of Integrated Arts and Sciences, Tokushima, Japan
| | - Yoshihiro Suzuki
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kenji Tani
- Department of General Medicine and Primary Care, Tokushima University Hospital, Tokushima, Japan
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Kitzinger J, Kitzinger C. Deaths after feeding-tube withdrawal from patients in vegetative and minimally conscious states: A qualitative study of family experience. Palliat Med 2018; 32:1180-1188. [PMID: 29569993 PMCID: PMC6041738 DOI: 10.1177/0269216318766430] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Families of patients in vegetative or minimally conscious states are often horrified by the suggestion of withdrawing a feeding tube, even when they believe that their relative would not have wanted to be maintained in their current condition. Very little is known about what it is like to witness such a death. AIM To understand these families' experience of their relatives' deaths. DESIGN Qualitative study using in-depth narrative interviews analyzed inductively with thematic analysis. PARTICIPANTS A total of 21 people (from 12 families) whose vegetative or minimally conscious relative died following court-authorized withdrawal of artificial nutrition and hydration. All had supported treatment withdrawal. FINDINGS Interviewees were usually anxious in advance about the nature of the death and had sometimes confronted resistance from, and been provided with misinformation by, healthcare staff in long-term care settings. However, they overwhelmingly described deaths as peaceful and sometimes even as a "good death." There was (for some) a significant "burden of witness" associated with the length of time it took the person to die and/or distressing changes in their appearance. Most continued to voice ethical objections to the manner of death while considering it "the least worst" option in the circumstances. CONCLUSION Staff need to be aware of the distinctive issues around care for this patient group and their families. It is important to challenge misinformation and initiate honest discussions about feeding-tube withdrawal and end-of-life care for these patients. Families (and staff) need better support in managing the "burden of witness" associated with these deaths.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Culture, Cardiff University, Cardiff, UK
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Hamuro A, Honda M, Tanaka R. Oral care and prevention of pneumonia after withdrawal of nasogastric tube feeding in three elderly patients with psychiatric disorders. Clin Case Rep 2018; 6:68-70. [PMID: 29375840 PMCID: PMC5771932 DOI: 10.1002/ccr3.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/30/2017] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
We investigated the effect of oral care on the prevention of pneumonia using a clinical scoring scale in elderly patients with psychiatric disorders after the withdrawal of nasogastric feeding tubes. Notably, oral care was effective in preventing pneumonia relapse in these patients.
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Affiliation(s)
- Atsushi Hamuro
- Department of Psychiatry; Yuzuriha Hospital; Nagasaki Japan
| | - Minoru Honda
- Department of Nursing; Yuzuriha Hospital; Nagasaki Japan
| | - Ryuichi Tanaka
- Department of Dentistry; Yuzuriha Hospital; Nagasaki Japan
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Gieniusz M, Sinvani L, Kozikowski A, Patel V, Nouryan C, Williams MS, Kohn N, Pekmezaris R, Wolf‐Klein G. Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”? J Am Geriatr Soc 2017; 66:64-69. [DOI: 10.1111/jgs.15125] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Marzena Gieniusz
- Division of Geriatric and Palliative MedicineNorthwell Health Manhasset New York
| | - Liron Sinvani
- Department of Medicine Northwell HealthManhasset New York
| | | | - Vidhi Patel
- Department of Medicine Northwell HealthManhasset New York
| | | | | | - Nina Kohn
- Feinstein Institute for Medical Research Manhasset New York
| | | | - Gisele Wolf‐Klein
- Division of Geriatric and Palliative MedicineNorthwell Health Manhasset New York
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Kurien M, Andrews RE, Tattersall R, McAlindon ME, Wong EF, Johnston AJ, Hoeroldt B, Dear KL, Sanders DS. Gastrostomies Preserve But Do Not Increase Quality of Life for Patients and Caregivers. Clin Gastroenterol Hepatol 2017; 15:1047-1054. [PMID: 27840184 DOI: 10.1016/j.cgh.2016.10.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/07/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurologic conditions that affect swallowing (eg, following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers. METHODS We performed a study of 100 patients who received gastrostomies (55% percutaneous endoscopic gastrostomy, 45% radiologically inserted) at 5 centers in the United Kingdom, 100 caregivers, and 200 population control subjects. We used the EuroQol-5D (comprising a questionnaire, index, visual analogue scale) to assess HRQoL for patients and caregivers before the gastrostomy insertion and then 3 months afterward; findings were compared with those from control subjects. Ten patients and 10 caregivers were also interviewed after the procedure to explore quantitative findings. Findings from the EuroQol-5D and semi-structured interviews were integrated using a mixed-methods matrix. RESULTS Six patients died before the 3-month HRQoL reassessments. We observed no significant longitudinal changes in mean EuroQol-5D index scores for patients (0.70 before vs 0.710 after; P = .83) or caregivers (0.95 before vs 0.95 after; P = .32) following gastrostomy insertion. The semi-structured interviews revealed problems in managing gastrostomy tubes, social isolation, and psychological and emotional consequences that reduced HRQoL. CONCLUSIONS We performed a mixed-methods prospective study of the effects of gastrostomy feeding on HRQoL. HRQoL did not significantly improve after gastrostomy insertion for patients or caregivers. The lack of significant decrease in HRQoL after the procedure indicates that gastrostomies may help maintain HRQoL. Findings have relevance to those involved in gastrostomy insertion decisions and indicate the importance of carefully selecting patients for this intervention, despite the relative ease of insertion.
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Affiliation(s)
- Matthew Kurien
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; Academic Unit of Gastroenterology, University of Sheffield, Sheffield, United Kingdom.
| | - Rebecca E Andrews
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Rachel Tattersall
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Mark E McAlindon
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Emma F Wong
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Alex J Johnston
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Barbara Hoeroldt
- Department of Gastroenterology, Rotherham General Hospital, Rotherham, United Kingdom
| | - Keith L Dear
- Department of Gastroenterology, Chesterfield Royal Hospital, Chesterfield, United Kingdom
| | - David S Sanders
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; Academic Unit of Gastroenterology, University of Sheffield, Sheffield, United Kingdom
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Boccardi V, Ruggiero C, Patriti A, Marano L. Diagnostic Assessment and Management of Dysphagia in Patients with Alzheimer's Disease. J Alzheimers Dis 2016; 50:947-55. [PMID: 26836016 DOI: 10.3233/jad-150931] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A growing concern in patients affected by Alzheimer's disease (AD) is dysphagia, or swallowing impairment, which leads to malnutrition, dehydration, weight loss, functional decline and fear of eating and drinking, as well as a decrease in the quality of life. Thus the diagnostic assessment of dysphagia in patients with AD is imperative to ensure that they receive effective management, avoiding complications, and reducing comorbidity and mortality in such a growing population. Dysphagia management requires a multidisciplinary approach considering that no single strategy is appropriate for all patients. However, evidence for clinical diagnostic assessment, interventions, and medical management of dysphagia in these patients are still limited: few studies are reporting the evaluation and the management among this group of patients. Here we analyzed the most recent findings in diagnostic assessment and management of swallowing impairment in patients affected by AD.
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Affiliation(s)
- Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Carmelinda Ruggiero
- Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Alberto Patriti
- General, Minimally Invasive and Robotic Surgery, Department of Surgery, "San Matteo degli Infermi" Hospital, ASL Umbria 2, Spoleto, Italy
| | - Luigi Marano
- General, Minimally Invasive and Robotic Surgery, Department of Surgery, "San Matteo degli Infermi" Hospital, ASL Umbria 2, Spoleto, Italy
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Abstract
Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding. With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients.
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Denning DW, Cadranel J, Beigelman-Aubry C, Ader F, Chakrabarti A, Blot S, Ullmann AJ, Dimopoulos G, Lange C. Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management. Eur Respir J 2016; 47:45-68. [PMID: 26699723 DOI: 10.1183/13993003.00583-2015] [Citation(s) in RCA: 520] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chronic pulmonary aspergillosis (CPA) is an uncommon and problematic pulmonary disease, complicating many other respiratory disorders, thought to affect ~240 000 people in Europe. The most common form of CPA is chronic cavitary pulmonary aspergillosis (CCPA), which untreated may progress to chronic fibrosing pulmonary aspergillosis. Less common manifestations include: Aspergillus nodule and single aspergilloma. All these entities are found in non-immunocompromised patients with prior or current lung disease. Subacute invasive pulmonary aspergillosis (formerly called chronic necrotising pulmonary aspergillosis) is a more rapidly progressive infection (<3 months) usually found in moderately immunocompromised patients, which should be managed as invasive aspergillosis. Few clinical guidelines have been previously proposed for either diagnosis or management of CPA. A group of experts convened to develop clinical, radiological and microbiological guidelines. The diagnosis of CPA requires a combination of characteristics: one or more cavities with or without a fungal ball present or nodules on thoracic imaging, direct evidence of Aspergillus infection (microscopy or culture from biopsy) or an immunological response to Aspergillus spp. and exclusion of alternative diagnoses, all present for at least 3 months. Aspergillus antibody (precipitins) is elevated in over 90% of patients. Surgical excision of simple aspergilloma is recommended, if technically possible, and preferably via video-assisted thoracic surgery technique. Long-term oral antifungal therapy is recommended for CCPA to improve overall health status and respiratory symptoms, arrest haemoptysis and prevent progression. Careful monitoring of azole serum concentrations, drug interactions and possible toxicities is recommended. Haemoptysis may be controlled with tranexamic acid and bronchial artery embolisation, rarely surgical resection, and may be a sign of therapeutic failure and/or antifungal resistance. Patients with single Aspergillus nodules only need antifungal therapy if not fully resected, but if multiple they may benefit from antifungal treatment, and require careful follow-up.
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Affiliation(s)
- David W Denning
- The National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and the Manchester Academic Health Science Centre, Manchester, UK
| | - Jacques Cadranel
- Service de Pneumologie, AP-HP, Hôpital Tenon and Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | | | - Florence Ader
- Dept of Infectious Diseases, Hospices Civils de Lyon, Lyon, France Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, Lyon, France
| | - Arunaloke Chakrabarti
- Center of Advanced Research in Medical Mycology, Dept of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Stijn Blot
- Dept of Internal Medicine, Ghent University, Ghent, Belgium Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - Andrew J Ullmann
- Dept of Internal Medicine II, Division of Infectious Diseases, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - George Dimopoulos
- Dept of Critical and Respiratory Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
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Zapka J, Amella E, Magwood G, Madisetti M, Garrow D, Batchelor-Aselage M. Challenges in efficacy research: the case of feeding alternatives in patients with dementia. J Adv Nurs 2014; 70:2072-2085. [PMID: 24612316 PMCID: PMC4130777 DOI: 10.1111/jan.12365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
AIMS To explore factors at the family caregiver and nursing home administrative levels that may affect participation in a clinical trial to determine the efficacy of hand feeding vs. percutaneous gastrostomy tube feeding in persons with late-stage dementia. BACKGROUND Decision-making regarding use of tube feeding vs. hand feeding for persons with late-stage dementia is fraught with practical, emotional and ethical issues and is not informed by high levels of evidence. DESIGN Qualitative case study. METHODS Transcripts of focus groups with family caregivers were reviewed for themes guided by behavioural theory. Analyses of notes from contacts with nursing home administrators and staff were reviewed for themes guided by an organizational readiness model. Data were collected between the years 2009-2012. RESULTS Factors related to caregiver willingness to participate included understanding of the prognosis of dementia, perceptions of feeding needs and clarity about research protocols. Nursing home willingness to participate was influenced by corporate approval, concerns about legal and regulatory issues, and prior relationships with investigators. CONCLUSION Participation in rigorous trials requires lengthy navigation of complex corporate requirements and training competent study staff. Objective deliberation by caregivers will depend on appropriate recruitment timing, design of recruitment materials and understanding of study requirements. The clinical standards and policy environment and the secular trends there-in have relevance to the responses of people at all levels.
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Affiliation(s)
- Jane Zapka
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elaine Amella
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gayenell Magwood
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohan Madisetti
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donald Garrow
- Gulf Comprehensive Gastroenterology, Englewood, Florida, USA
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Abraham RR, Girotra M, Wei JY, Azhar G. Is short-term percutaneous endoscopic gastrostomy tube placement beneficial in acutely ill cognitively intact elderly patients? A proposed decision-making algorithm. Geriatr Gerontol Int 2014; 15:572-8. [PMID: 25109444 DOI: 10.1111/ggi.12316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2014] [Indexed: 11/27/2022]
Abstract
AIM Percutaneous endoscopic gastrostomy (PEG) tube is an important method of enteral feeding for patients who require temporary or long-term artificial nutritional support to prevent or correct disease-related malnutrition. However, there is paucity of data on the utility of short-term PEG tube placements in acute illnesses in cognitively intact older adults. METHODS We present a series of seven, cognitively intact patients (age range 72-93 years), who had PEG tubes placed for short periods. These patients were diagnosed with "failure to thrive" and were managed by placing a PEG tube temporarily for nutritional management. None of these patients had terminal illness or hospice eligibility, and all of the patients were community dwellers. RESULTS All of the elderly patients experienced good outcomes in terms of their functional status and nutritional support. CONCLUSIONS Our series clearly supports the notion that short-term PEG tube placement in cognitively intact elderly patients could be a successful strategy to support them during an episode of acute illness, and to improve their nutritional deficits and survival.
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Affiliation(s)
- Rtika R Abraham
- Department of Geriatrics and Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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18
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Oral care may reduce pneumonia in the tube-fed elderly: a preliminary study. Dysphagia 2014; 29:616-21. [PMID: 25034303 DOI: 10.1007/s00455-014-9553-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 06/17/2014] [Indexed: 01/15/2023]
Abstract
Pneumonia is one of the most important diseases in terms of mortality in the elderly. In particular, bedridden patients who are forbidden oral ingestion during enteral nutrition may have a poor outcome resulting from a respiratory infection. Oral hygiene can play a positive role in preventing aspiration pneumonia in the elderly. The aim of this study was to investigate the effectiveness of oral hygiene for bedridden and tube-fed patients at an increased risk of pneumonia. This retrospective study was conducted from July 2011 to June 2013 on a long-term-care hospital unit. The oral care protocol (OCP) intervention commenced in July 2012, during the study period. The subjects of this study were 63 elderly patients with a mean age of 81.7 years. Thirty-one patients were enrolled in the OCP intervention group, and the mean observation length was 130.4 days; the mean observation length for the 32 patients in the control group was 128.4 days. The incidence of pneumonia and the numbers of days with a recorded fever, antibiotics administration, blood tests, and radiological examinations were reduced from 1.20 to 0.45, 24.57 to 17.48, 25.52 to 10.12, 10.91 to 6.54, and 6.33 to 3.09 %, respectively. These reductions were significantly less in the OCP intervention group. In conclusion, the results of the present study suggest that daily oral care for tube-fed patients who do not receive nutrition by mouth reduced the incidence of pneumonia. In addition to patients consuming food by mouth, all tube-fed patients require dedicated oral care to maintain healthy oral conditions.
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Stephens CE, Sackett N, Govindarajan P, Lee SJ. Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr 2014; 14:35. [PMID: 24650076 PMCID: PMC3994482 DOI: 10.1186/1471-2318-14-35] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/07/2014] [Indexed: 11/24/2022] Open
Abstract
Background Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI. Methods We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors. Results Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations. Conclusions ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, University of California San Francisco, 2 Koret Way, #N531E, San Francisco, CA 94143-0608, USA.
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Roza KA, Horton JR, Johnson K, Anderson WG. Update in hospice and palliative care. J Palliat Med 2014; 17:351-7. [PMID: 24548140 DOI: 10.1089/jpm.2013.0577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katherine A Roza
- 1 Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai , New York, New York
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Hasegawa H, Samuel M, Douiri A, Ashkan K. Patients' expectations in subthalamic nucleus deep brain stimulation surgery for Parkinson disease. World Neurosurg 2014; 82:1295-1299.e2. [PMID: 24518887 DOI: 10.1016/j.wneu.2014.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Subthalamic nucleus (STN) deep brain stimulation (DBS) is an established treatment for patients with advanced Parkinson disease. However, some patients feel less satisfied with the outcome of surgery. We sought to study the relationship between expectations, satisfaction, and outcome in STN DBS for Parkinson disease. METHODS Twenty-two consecutive patients undergoing STN DBS completed a modified 39-item Parkinson disease questionnaire (PDQ-39) preoperatively and 6 months postoperatively. A satisfaction questionnaire accompanied the postoperative questionnaire. RESULTS Patients expected a significant improvement from surgery preoperatively: preoperative score (median PDQ-39 summary score [interquartile range]): 37.0 (9.5), expected postoperative score: 13.0 (8.0), P < 0.001. Patients improved after surgery (preoperative score 39.0 [11.5], postoperative score 25.0 [14.3], P = 0.003), although there was a substantial disparity between the expected change (24.0 [15.0]) and actual change (14.0 [22.5]), P = 0.008. However, most patients felt that surgery fulfilled their expectations (mean score on a 0%-100% visual analog scale); (75.3 ± 17.8) and were satisfied (73.3 ± 25.3). Satisfaction correlated with fulfillment of expectations (r = 0.910, P < 0.001) but not with quantitative changes in PDQ-39 scores. CONCLUSIONS Addressing patients' expectations both preoperatively and postoperatively may play an important role in patient satisfaction, and therefore overall success, of STN DBS surgery for Parkinson disease.
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Affiliation(s)
- Harutomo Hasegawa
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, United Kingdom.
| | - Michael Samuel
- Department of Neurology, King's College Hospital, Denmark Hill, London, United Kingdom; Department of Neurology, East Kent Hospitals NHS University Foundation Trust, Canterbury, Kent, United Kingdom
| | - Abdel Douiri
- Department of Public Health Sciences, King's College London, London, United Kingdom; NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London, United Kingdom; Department of Clinical Neurosciences, Institute of Psychiatry, King's College London, London, United Kingdom
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22
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Shaw C, Power J. Nutritional Support for the Cancer Patient. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Martins AS, Rezende NAD, Torres HODG. Occurrence of complications and survival rates in elderly with neurological disorders undergoing enteral nutrition therapy. Rev Assoc Med Bras (1992) 2013; 58:691-7. [PMID: 23250098 DOI: 10.1590/s0104-42302012000600014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 07/10/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the occurrence of complications, as well as the survival rates, in elderly people having neurological diseases and undergoing enteral nutrition therapy (ENT). METHODS Patients aged over 60 years, assisted by a home medical service from a healthcare plan in the city of Belo Horizonte, MG, Brazil, were thoroughly evaluated. The mentioned evaluation occurred at their homes after hospital discharge with enteral nutrition (EN) after a three-month period, a six-month period, and at the end of the study. A nutritional assessment was performed along with data collection performed on the patients' electronic medical records, and interviews performed with patients' family members and caregivers. RESULTS Seventy-nine patients aged 82.9 ± 10.4 years old were evaluated; of these, 49.4% presented dementia, and 50.6% presented other neurological diagnoses. 100% of patients presented a high dependence level, assessed by the Katz index. The majority of patients (91.2%) presented some complications such as: pneumonia, catheter loss, diarrhea, constipation, vomiting, fluid leakage, periostotomy, tube obstruction, reflux, and myiasis. Pneumonia was the most frequent complication, occurring in 55.9% of cases. The mortality rates were 15.2% at a three-month period, 22.8% at a six-month period, and 43% at the end of study. The median survival after starting EN was 364 days. Differences among the mortality rate and neurological diagnosis, EN routes of access, and complications were not observed. The survival rate was lower in patients having inadequate nutritional status and albumin levels < 3.5 mg/dL. CONCLUSION The population followed presented a high rate of complications and death at the end of the study. Diagnosis of dementia, EN routes of access, as well as complications, did not influence the survival rates. However, inadequate nutritional status according to the clinical assessment and albumin levels lower than 3.5 mg/dL significantly influenced the survival rates.
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Alivizatos V, Gavala V, Alexopoulos P, Apostolopoulos A, Bajrucevic S. Feeding Tube-related Complications and Problems in Patients Receiving Long-term Home Enteral Nutrition. Indian J Palliat Care 2013; 18:31-3. [PMID: 22837608 PMCID: PMC3401731 DOI: 10.4103/0973-1075.97346] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM The aim of this study was to evaluate the long-term complications and problems related to gastrostomy and jejunostomy feeding tubes used for home enteral nutrition support and the effect these have on health care use. MATERIALS AND METHODS The medical records of 31 patients having gastrostomy (27 patients) and jejunostomy (4) feeding tubes inserted in our Department were retrospectively studied. All were discharged on long-term (>3 months) enteral nutrition and followed up at regular intervals by a dedicated nurse. Any problem or complication associated with tube feeding as well as the intervention, if any, that occurred, was recorded. Data were collected and analyzed. RESULTS All the patients were followed up for a mean of 17.5 months (4-78). The most frequent tube-related complications included inadvertent removal of the tube (broken tube, plugged tube; 45.1%), tube leakage (6.4%), dermatitis of the stoma (6.4%), and diarrhea (6.4%). There were 92 unscheduled health care contacts, with an average rate of such 2.9 contacts over the mean follow-up time of 17.5 months. CONCLUSION In patients receiving long-term home enteral nutrition, feeding tube-related complications and problems are frequent and result in significant health care use. Further studies are needed to address their optimal prevention modalities and management.
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Affiliation(s)
- Vasileios Alivizatos
- Department of Surgery and Artificial Nutrition Unit, "St. Andrew" General Hospital, Patra, Greece
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Finley MR, Macias RL, Becho J, Wood RC, Hernandez AE, Espino DV. Correlates associated with the desire for PEG tube placement at the end of life among community-dwelling older Mexican Americans: a pilot study. Aging Clin Exp Res 2013; 25:69-74. [PMID: 23740635 DOI: 10.1007/s40520-013-0005-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 11/23/2011] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND AIMS Use of percutaneous endoscopic gastrostomy (PEG) tubes in older adults remains controversial. This cross-sectional study examines community-dwelling Mexican American older adults' attitudes toward PEG tube placement in the hypothetical event of a terminal illness. METHODS Interviews were conducted with 100 community-dwelling Mexican American (MA's) adults, age 60 and over, in San Antonio, Texas. Subjects were screened for cognitive competence using Folstein's mini-mental examination. This was followed by an evaluation of socioeconomic status, depressive symptoms, religiosity, health status and attitudes toward end-of-life care, including PEG tube feeding. RESULTS Higher income MA's, professionals, those without a living will, those who saw religious belief as not important and those who attended church less than once a month were more likely to agree with PEG placement (all P < 0.05). Logistic regression analysis revealed that higher income (OR = 3.16, CI = 1.13-8.83), lack of a living will (OR = 3.34, CI = 1.03-20.87) and low importance of religious beliefs (OR = 7.14, CI = 1.25-41.67) were all independently associated with the desire for insertion of a PEG tube at the end of life. CONCLUSIONS This is the first community-based study to describe older Mexican American's attitudes toward PEG tube placement at the end of life. Older community-dwelling Mexican Americans with higher incomes, lack of a living will or low religious involvement might be more likely to choose PEG tube placement even in the context of a terminal condition.
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Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do patients with advanced cognitive impairment admitted to hospitals with higher rates of feeding tube insertion have improved survival? J Pain Symptom Manage 2013; 45:524-33. [PMID: 22871537 PMCID: PMC3594461 DOI: 10.1016/j.jpainsymman.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 02/22/2012] [Accepted: 02/23/2012] [Indexed: 11/30/2022]
Abstract
CONTEXT Research is conflicting on whether receiving medical care at a hospital with more aggressive treatment patterns improves survival. OBJECTIVES The aim of this study was to examine whether nursing home residents admitted to hospitals with more aggressive patterns of feeding tube insertion had improved survival. METHODS Using the 1999-2007 Minimum Data Set matched to Medicare claims, we identified hospitalized nursing home residents with advanced cognitive impairment who did not have a feeding tube inserted prior to their hospital admissions. The sample included 56,824 nursing home residents and 1773 acute care hospitals nationwide. Hospitals were categorized into nine groups based on feeding tube insertion rates and whether the rates were increasing, staying the same, or decreasing between the periods of 2000-2003 and 2004-2007. Multivariate logit models were used to examine the association between the hospital patterns of feeding tube insertion and survival among hospitalized nursing home residents with advanced cognitive impairment. RESULTS Nearly one in five hospitals (N=366) had persistently high rates of feeding tube insertion. Being admitted to these hospitals with persistently high rates of feeding tube insertion was not associated with improved survival when compared with being admitted to hospitals with persistently low rates of feeding tube insertion. The adjusted odds ratios were 0.93 (95% confidence interval [CI]: 0.87, 1.01) and 1.02 (95% CI: 0.95, 1.09) for one-month and six-month posthospitalization survival, respectively. CONCLUSION Hospitals with more aggressive patterns of feeding tube insertion did not have improved survival for hospitalized nursing home residents with advanced cognitive impairment.
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Affiliation(s)
- Shubing Cai
- Program in Public Health, Department of Health Services, Policy & Practice, Brown University, Providence, RI 02912, USA.
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Snyder EA, Caprio AJ, Wessell K, Lin FC, Hanson LC. Impact of a decision aid on surrogate decision-makers' perceptions of feeding options for patients with dementia. J Am Med Dir Assoc 2012; 14:114-8. [PMID: 23273855 DOI: 10.1016/j.jamda.2012.10.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/14/2012] [Accepted: 10/19/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In advanced dementia, feeding problems are nearly universal, and families face difficult decisions about feeding options. Initial interviews for a randomized trial were used to describe surrogates' perceptions of feeding options, and to determine whether a decision aid on feeding options in advanced dementia would improve knowledge, reduce expectation of benefit from tube feeding, and reduce conflict over treatment choices for persons with advanced dementia. DESIGN Semistructured interview with prestudy and poststudy design for surrogates in the intervention group. SETTING Twenty-four skilled nursing facilities across North Carolina participating in a cluster randomized trial. PARTICIPANTS Two hundred and fifty-five surrogate decision makers for nursing home residents with advanced dementia and feeding problems, in control (n = 129) and intervention (n = 126) groups. INTERVENTION For intervention surrogates only, an audiovisual-print decision aid provided information on dementia, feeding problems in dementia, advantages and disadvantages of feeding tubes or assisted oral feeding options, and the role of surrogates in making these decisions. MEASUREMENTS The interview included open-ended items asking surrogates to report advantages and disadvantages of tube feeding and assisted oral feeding. Knowledge of feeding options was measured with 19 true/false items and items measuring expectation of benefit from tube feeding. Surrogates reported which of these two feeding options they preferred for the person with dementia, and how confident they were in this choice; their level of conflict about the choice was measured using the decisional conflict scale. RESULTS Before the decision aid, surrogates described advantages and disadvantages of assisted oral feeding and tube feeding in practical, ethical, and medical terms. After review of the decision aid, intervention surrogates had improved knowledge scores (15.5 vs 16.8; P < .001), decreased expectation of benefits from tube feeding (2.73 vs 2.32; P = .001), and reduced decisional conflict (2.24 vs 1.91; P < .001). Surrogates preferred assisted oral feeding initially and reported more certainty about this choice after the decision aid. CONCLUSIONS A structured decision aid can be used to improve decision making about feeding options in dementia care.
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Affiliation(s)
- E Amanda Snyder
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina, Chapel Hill, NC 27759, USA
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Sobrevida e complicações em idosos com doenças neurológicas em nutrição enteral. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70273-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes RL, Bynum JPW, Mor V. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc 2012; 60:1918-21. [PMID: 23002947 DOI: 10.1111/j.1532-5415.2012.04148.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival. DESIGN Prospective cohort study. SETTING All U.S. nursing homes (NHs). PARTICIPANTS Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007. MEASUREMENTS Survival after development of the need for eating assistance and feeding tube insertion. RESULTS Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion). CONCLUSION Neither insertion of PEG tubes nor timing of insertion affect survival.
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Affiliation(s)
- Joan M Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA.
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Zieschang T, Oster P, Pfisterer M, Schneider N. Palliativversorgung von Menschen mit Demenz. Z Gerontol Geriatr 2012; 45:50-4. [DOI: 10.1007/s00391-011-0270-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 10/18/2011] [Indexed: 10/14/2022]
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del Río M, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, Nervi F. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psychooncology 2011; 21:913-21. [DOI: 10.1002/pon.2099] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 10/13/2011] [Accepted: 10/15/2011] [Indexed: 11/10/2022]
Affiliation(s)
- M. I. del Río
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - B. Shand
- Departamento de Neurología; Pontificia Universidad Católica de Chile; Santiago Chile
| | - P. Bonati
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - A. Palma
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - A. Maldonado
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
| | - P. Taboada
- Centro de Bioética; Pontificia Universidad Católica de Chile; Santiago Chile
| | - F. Nervi
- Programa de Medicina Paliativa y Cuidados Continuos; Departamento de Medicina Interna, Pontificia Universidad Católica de Chile; Santiago Chile
- División de Medicina, Departamento de Gastroenterología; Pontificia Universidad Católica de Chile; Santiago Chile
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Hanson LC, Carey TS, Caprio AJ, Lee TJ, Ersek M, Garrett J, Jackman A, Gilliam R, Wessell K, Mitchell SL. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc 2011; 59:2009-16. [PMID: 22091750 DOI: 10.1111/j.1532-5415.2011.03629.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To test whether a decision aid improves quality of decision-making about feeding options in advanced dementia. DESIGN Cluster randomized controlled trial. SETTING Twenty-four nursing homes in North Carolina. PARTICIPANTS Residents with advanced dementia and feeding problems and their surrogates. INTERVENTION Intervention surrogates received an audio or print decision aid on feeding options in advanced dementia. Controls received usual care. MEASUREMENTS Primary outcome was the Decisional Conflict Scale (range: 1-5) measured at 3 months; other main outcomes were surrogate knowledge, frequency of communication with providers, and feeding treatment use. RESULTS Two hundred fifty-six residents and surrogate decision-makers were recruited. Residents' average age was 85; 67% were Caucasian, and 79% were women. Surrogates' average age was 59; 67% were Caucasian, and 70% were residents' children. The intervention improved knowledge scores (16.8 vs 15.1, P < .001). After 3 months, intervention surrogates had lower Decisional Conflict Scale scores than controls (1.65 vs 1.90, P < .001) and more often discussed feeding options with a healthcare provider (46% vs 33%, P = .04). Residents in the intervention group were more likely to receive a dysphagia diet (89% vs 76%, P = .04) and showed a trend toward greater staff eating assistance (20% vs 10%, P = .08). Tube feeding was rare in both groups even after 9 months (1 intervention vs 3 control, P = .34). CONCLUSION A decision aid about feeding options in advanced dementia reduced decisional conflict for surrogates and increased their knowledge and communication about feeding options with providers.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Mayre-Chilton KM, Talwar BP, Goff LM. Different experiences and perspectives between head and neck cancer patients and their care-givers on their daily impact of a gastrostomy tube. J Hum Nutr Diet 2011; 24:449-59. [PMID: 21649745 DOI: 10.1111/j.1365-277x.2011.01165.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gastrostomy feeding in head and neck cancer patients is recognised standard practice in some cancer centres with beneficial effects on outcomes for appropriately selected patients. However, the impact on patients and care-givers needs consideration. The present study aimed to understand the daily impact of gastrostomy feeding on head and neck cancer patients and their care-givers to identify improvements to services. METHODS Twenty-one adult patients were randomly selected from the Head and Neck centre at University College London Hospital. Six head and neck cancer patients and three care-givers participated in focus groups. The sessions were recorded, fully transcribed and qualitatively thematically analysed, and the resulting data were tabulated. RESULTS Patients and care-givers expressed opposite experiences within knowledge and understanding of why the tube was necessary; their personal perceptions and objectives of nutritional support. Themes expressing similar experiences included: developing positive coping strategies; preventing nutritional decline; tube dependency; dentures; finance; active care; and psychological support. Furthermore, both groups expressed the benefits of retaining a support network for rehabilitation with the hospital-based specialist team. Also patients and carers recognised that the gastrostomy tube helped patient survival and, with timely dietetic management, helped them wean off the tube reliance with more confidence. CONCLUSIONS It is essential that patients and care-givers attend pretreatment clinics to discuss nutritional support via the artificial route; their quality of life can be enhanced if guided through a specialist support pathway based at the clinical site where they initiated their care, with links to key agencies.
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Affiliation(s)
- K M Mayre-Chilton
- Food, Nutrition and Dietetics, Department of Health and Human Sciences, London Metropolitan University, London, UK
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Skitt LC, Hurley JJ, Turner JK, Green AJ, Pinch N, Dolwani S, Swift GL, Green T. Helping the general physician to improve outcomes after PEG insertion: how we changed our practice. Clin Med (Lond) 2011; 11:132-7. [PMID: 21526693 PMCID: PMC5922733 DOI: 10.7861/clinmedicine.11-2-132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
During their careers, most general physicians are involved in the decision-making process for patients that potentially require percutaneous endoscopic gastrostomy (PEG) insertion. However, poor patient selection and less than favourable outcomes are frequently observed in this group. With the aim of identifying and addressing the underlying issues, the PEG service at University Hospital Llandough was radically changed over an eight-year period. The development of a nurse-led pre-assessment service and design of a specific referral form was successful in reducing the number of PEG referrals and consequently the 30-day mortality rate. Furthermore, the educational and training needs of general physicians of all grades regarding the issues surrounding PEG placement were identified and addressed at formal teaching sessions. A combination of these factors has positively impacted on our service, with more appropriate patient selection and a reduced 30-day mortality rate.
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Abstract
UNLABELLED To review the benefits of oral feeding options in people with dementia. DESIGN Systematic literature search with review of potentially eligible studies by two independent investigators. SETTING PubMed/MEDLINE, EMBASE, the Cochrane Library, CINAHL, and PsychINFO literature indices between January 1990 and October 2009. PARTICIPANTS Clinical trials with random or nonrandom control groups were included if they reported on clinical outcomes of oral feeding interventions for people with dementia. MEASUREMENTS Investigators abstracted data from included studies using a structured instrument. Studies were graded on quality and potential bias, and overall strength of evidence was summarized. RESULTS Thirteen controlled trials provided data on use of supplements for people with dementia, and 12 controlled trials tested assisted feeding or other interventions. Studies provide moderate-strength evidence for high-calorie supplements, and low-strength evidence for appetite stimulants, assisted feeding, and modified foods to promote weight gain in people with dementia. The few studies measuring function or survival showed no difference. CONCLUSION High-calorie supplements and other oral feeding options can help people with dementia with feeding problems to gain weight; they are unlikely to improve other outcomes. These treatments can be offered alone or in combination as an alternative to tube feeding.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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Hanson LC, Garrett JM, Lewis C, Phifer N, Jackman A, Carey TS. Physicians' expectations of benefit from tube feeding. J Palliat Med 2009; 11:1130-4. [PMID: 18980454 DOI: 10.1089/jpm.2008.0033] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Tube feeding is increasingly common, despite evidence for limited medical benefits. We interviewed treating physicians to describe their expectation of benefit for patients receiving a new feeding tube, and to determine whether expected benefits vary by patient characteristics. METHODS We recruited treating physicians and surrogate decision-makers for 288 hospitalized patients in a prospective study of new feeding tube decisions. In structured interviews, physicians provided information on patients' diagnosis and whether they expected any of eight potential medical benefits for a specific patient; surrogates provided information about the patients' function, race, age, prior residence, and ability to eat by mouth. RESULTS We completed interviews with 173 physicians about tube feeding for 280 patients (response rate, 97%). Patients commonly had acute stroke (30%), neurodegenerative disease (16%), or head and neck cancer (22%); 70% were somewhat or severely malnourished. In half or more cases, physicians expected benefits of improved nutrition (93%), hydration (60%), prolonged life (58%), ease providing medication (55%), and less aspiration risk (49%). Physicians endorsed more expected benefits for patients with stroke or those completely unable to eat by mouth (p < 0.05). CONCLUSION Treating physicians expected multiple medical benefits for a diverse population of patients receiving feeding tubes. Physicians may be unaware of evidence, or expect more optimistic outcomes for their specific patient population. Further education and decision support may improve evidence-based decision-making about feeding tubes.
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Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, NC 27599-7550, USA.
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Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc 2009; 10:264-70. [PMID: 19426943 DOI: 10.1016/j.jamda.2008.10.010] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 10/23/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Despite the evidence that feeding-tube use in persons with advanced dementia is not associated with improved outcomes, there remains striking variation in their use. Yet, little is known about the national incidence of feeding-tube insertions, the circumstances of their insertion, and post-insertion health care use. DESIGN Secondary analysis of Minimum Data Set merged onto Medicare Claims Files. SETTING AND PARTICIPANTS Nursing home residents (NHR) without a feeding tube. MEASUREMENTS NHR were followed for up to 1 year to see whether a feeding tube was inserted and then followed for 1 year after insertion to examine health care use and survival. RESULTS The incidence of feeding-tube insertion was 53.6/1000 residents. Most (68.1%) feeding-tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within 1 year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over 1 year, tube feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission. CONCLUSION Most feeding tubes are inserted in an acute care hospital. Feeding-tube insertions are also associated with poor survival and significant rate of health care use after insertion.
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Fromme EK, Hughes MT, Brokaw FC, Rosenfeld KE, Arnold RM. Update in Palliative Medicine 2008. J Palliat Med 2008. [DOI: 10.1089/jpm.2008.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Erik K. Fromme
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon
| | - Mark T. Hughes
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francis C. Brokaw
- Division of General Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kenneth E. Rosenfeld
- Division of General Medicine, Palliative Care Section VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kehl KA. Caring for the Patient and the Family in the Last Hours of Life. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2008. [DOI: 10.1177/1084822307311839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recognition of the signs and symptoms that are common in the final hours of life and a basic understanding of how to manage these signs and symptoms are important to helping the patient and family experience a good death in the home setting. The most common signs and symptoms, including pain, dyspnea, and terminal restlessness or delirium, and their management are discussed. Also addressed are other signs and symptoms, such as cardiovascular signs and symptoms including cold extremities, mottling, and changes in vital signs; respiratory signs and symptoms such as changes in breathing pattern, noisy breathing, and mandibular breathing; and neurological signs and symptoms such as disorientation, sensory changes, and semicomatose state. Changes in metabolism such as fatigue, surge of energy, and increased temperature are presented, along with decreased intake, excretion, and communication changes.
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Abstract
Percutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking.
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Finucane TE, Christmas C, Leff BA. Tube feeding in dementia: how incentives undermine health care quality and patient safety. J Am Med Dir Assoc 2007; 8:205-8. [PMID: 17498602 DOI: 10.1016/j.jamda.2007.01.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 01/12/2007] [Indexed: 11/16/2022]
Abstract
For nursing home residents with advanced dementia, very little evidence is available to show clinical benefit from enteral tube feeding. Although no randomized clinical trials have been done, considerable evidence from studies of weaker design strongly suggest that tube feeding does not reduce the risks of death, aspiration pneumonia, pressure ulcers, other infections, or poor functional outcome. Nationally, however, utilization is high and highly variable. System-wide incentives favor use of tube feeding, and may influence substitute decision-makers, bedside clinicians, gastroenterologists, and administrators regardless of patient preferences or putative medical indications. Underlying the widespread use of this marginally effective therapy is a basic misunderstanding about malnutrition and about aspiration pneumonia. The face value of tube feeding is strong indeed. In addition to the general faith in intervention, the impulse to "do something" when things are going poorly, financial incentives favor tube feeding for gastroenterologists, hospitals, and nursing homes. The desire to avoid regulatory sanctions, bad publicity, and liability exposure creates a further incentive for nursing homes to provide tube feeding. Rational, evidence-based use of tube feeding in advanced dementia will depend fundamentally on improved education. Reimbursement schemes require significant modification to limit the irrational use of tube feeding. Nursing home regulations based more securely on scientific evidence would likely reduce nonbeneficial tube feeding, as would evidence-based tort reform. Quality improvement initiatives could create positive incentives. Realigning incentives in these ways could, we believe, improve the quality of care, quality of life, and safety of these vulnerable individuals, likely with reduced costs of care.
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