The Standard of Caring: Why Do We Still Use Feeding Tubes in Patients With Advanced Dementia?

Navigating late-stage dementia: A perspective from the Alzheimer's Association

Alzheimer's disease (AD) is the most common cause of dementia, a general term for memory loss and decline in other cognitive abilities enough to interfere with daily life. AD accounts for 60% to 80% of dementia cases. The late stage of AD tends to be the shortest stage and, on average, lasts 1 to 2 years. As this stage of the condition progresses, it requires continuous intensive long-term care and around-the-clock intensive care. The Alzheimer's Association stands firm in its commitment to supporting individuals living with AD and other dementia, their care partners, and their health-care providers as they navigate treatment and care decisions across the continuum of the disease. This article is a direct response to recently published works that run counter to the Association's viewpoint. It outlines the Association's perspective on crucial factors for consideration during late-stage dementia care, including advanced directives, palliative care, nutrition, and legal considerations. It explores diverse perspectives from the field, differing from the Alzheimer's Association's stance. Last, it underscores resources available through the Alzheimer's Association, aiming to present a comprehensive perspective on late-stage care for support and assistance to all involved.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia

OBJECTIVE

Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics.

METHOD

This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics.

RESULTS

Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult.

SIGNIFICANCE OF RESULTS

The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Palliative Care for Dementia: 2020 Update

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.

Perceptions of Reducing Tube Feeding for Persons with Advanced Dementia among Various Professions in a Teaching Hospital

BACKGROUND

Even though no evidence suggests tube feeding is beneficial for individuals with advanced dementia, many are still tube fed.

OBJECTIVE

To assess perceptions of hospital staff regarding reducing tube feeding (RTF) of patients with advanced dementia.

DESIGN

Cross-sectional survey.

SETTING

A regional teaching hospital in Taipei, Taiwan.

SUBJECTS

Hospital staff (n = 624), including physicians, nurses, dieticians, paramedical personnel, social workers, volunteers, attendants, and administrators.

MEASUREMENTS

Anonymous questionnaires.

RESULTS

The overall awareness of RTF for advanced dementia patients averaged 10.2 ± 3.74 points (maximum, 19 points) among all respondents. Among the different hospital professions, dieticians scored the highest, whereas nurses and attendants/volunteers had relatively low scores. Over half of respondents (57%) agreed tube feeding is the best choice for advanced dementia with dysphagia. Physicians of different specialties had significantly different responses toward RTF with regard to the belief that tube feeding reduces the risk of aspiration pneumonia, referring patients who refuse tube feeding to other health care team members, and the belief that family members would be able to accept the patient's death along with insufficient food/fluid intake. Only 35.1% of respondents believed they were able to implement comfort feeding.

CONCLUSIONS

The present survey shows a persistent knowledge gap among various health care professions regarding tube feeding of patients with advanced dementia. Also, there is insufficient awareness about this subject, indicating that promotion of comfort feeding by enhanced training and communication within medical teams is essential to achieving better person-centered care and preventing unnecessary suffering.

Palliative Care for Dementia

With the growing care needs for the older population at the end of their lives, there has been a substantial increase in attention to the management of the patient with dementia in hospice and palliative care services. This article reviews issues in access to care and the optimal management of the patient with dementia, particularly in the context of neuropsychiatric complexities. Special issues such as delirium, cachexia, behavioral symptoms, and pain management are addressed. Future challenges in research such as the development of better prognostic models are noted as well as the importance of attention to access to care.

Heterogeneity of patients receiving artificial nutrition in Japanese psychiatric hospitals: a cross-sectional study

AIM

Artificial nutrition, including tube feeding, continues to be given to dementia patients in numerous geriatric facilities in Japan. However, the clinical characteristics of patients receiving artificial nutrition have not been fully investigated. Therefore, we tried to evaluate the clinical features of those patients in this study.

METHODS

Various clinical characteristics of all inpatients at 18 of 20 psychiatric hospitals in Okayama Prefecture, Japan, with a percutaneous endoscopic gastrostomy tube, nasogastric tube, or total parenteral nutrition were evaluated.

RESULTS

Two hundred twenty-one patients (5.4% of all inpatients) had been receiving artificial nutrition for more than 1 month, and 187 (130 women, 57 men; 84.6% of 221 patients) were fully investigated. The mean age was 78.3 years old, and the mean duration of artificial nutrition was 29.8 months. Eighty-four patients (44.7% of 187 patients) were receiving artificial nutrition for more than 2 years. Patients with Alzheimer's disease (n = 78) formed the biggest group, schizophrenia (n = 37) the second, and vascular dementia (n = 26) the third.

CONCLUSION

About one-fifth of the subjects receiving artificial nutrition were in a vegetative state. More than a few patients with mental disorders, including schizophrenia, also received long-term artificial nutrition. We should pay more attention to chronic dysphasia syndrome in mental disorders.

[Choosing wisely together with the patient]

Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.

ESPEN guideline on ethical aspects of artificial nutrition and hydration

BACKGROUND

The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient.

METHODS

The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members.

RESULTS

The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.

Person-centered Feeding Care: A Protocol to Re-introduce Oral Feeding for Nursing Home Patients with Tube Feeding

BACKGROUND

Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.

METHODS

This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai'i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.

RESULTS

Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).

CONCLUSION

Using findings from our retrospective study of usual care, our NH's interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.

Hospice utilization in nursing homes: association with facility end-of-life care practices

OBJECTIVES

Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay.

DESIGN

The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey).

SETTING AND PARTICIPANTS

In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study.

MEASUREMENTS

We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims.

RESULTS

The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death.

CONCLUSION

Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.

Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia

AIM

Unexpected death from suffocation as a result of ortholaryngeal mucinous secretions or vomitus during recovery from pneumonia is devastating for patients, their families and medical professionals. This study aimed to determine the risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia.

METHODS

This study was carried out with patients aged 65 years and older that were hospitalized for pneumonia and died of any cause. Unexpected death from suffocation was defined as: (i) being in the recovery stage of pneumonia; (ii) presenting stable vital signs a week before death; (iii) dying within 24 h after suffocation; and (iv) aspiration confirmed by transtracheal suction. The clinical features and courses, and methods of feeding were retrospectively analyzed.

RESULTS

A total of 11 patients that had an unexpected death from suffocation and 62 patients who died of other causes were enrolled. There were significantly more patients that received tube feeding after admission (continuation and introduction) among the patients who had died of suffocation (63.6%) than in those who had died of other causes (12.9%; P < 0.001). A multiple logistic regression analysis showed that tube feeding after admission was strongly associated with unexpected death from suffocation (adjusted odds ratio 9.536, P = 0.047) after adjusting for sex, age, level of serum albumin, PaO2 /FIO2 ratio, the pneumonia severity score and performance status.

CONCLUSION

A continuation of tube feeding after admission is thus considered to be a significant predictor of unexpected death from suffocation in elderly patients with pneumonia.

Testing the medical covenant: caring for patients with advanced dementia

End-of-life care, particularly for patients with advanced dementia, tests the medical covenant, both the integrity and aptness of what physicians have to offer and the fidelity with which they offer it. This article considers five ways of justifying the unilateral withholding of future treatment: (1) an affirmation of professional autonomy; (2) a defense of professional integrity; (3) a parentalist exercise of power on behalf of the patient and/or family; (4) a protection of the interests of third parties (footing the bill); or (5) a protection of the interests of second parties (the physician or other providers). The article concludes with a sixth response to care for the stricken patient and family that seeks to attend more fully to the clinical reality of bonded humans in the throes of disease and death.

Doing the right thing: a geriatrician's perspective on medical care for the person with advanced dementia

Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. Physicians are the locus of decision making for persons with dementia. It is the responsibility of the physician to assure that the surrogate understands the nature and trajectory of the disease and then to elicit the desired goal of care. Physicians need to ascertain whether any advance directives are available, and if so, whether they apply to the situation of advanced dementia. Finally, physicians should help surrogates understand how the goals of care are best translated into practice. When the goal is comfort, this is achieved by assuring dignity, minimizing suffering, and promoting caring. In general, comfort should be the default goal of care, best implemented through palliative care or hospice.

Tube feeding in patients with advanced dementia: knowledge and practice of speech-language pathologists

CONTEXT

Speech-language pathologists (SLP) are often called on to evaluate eating difficulties in patients with dementia.

OBJECTIVES

To assess factors associated with SLPs' knowledge and recommendations about feeding tubes in patients with advanced dementia.

METHODS

A mail survey was administered to a probability sample of 1500 SLPs from the American Speech-Language-Hearing Association mailing list; 731 usable surveys were received (response rate=53.7%). Self-perceived preparedness, knowledge, and care recommendations were measured. Knowledge items were scored as "evidence based" or not according to the best evidence in the literature.

RESULTS

Only 42.1% of SLP respondents felt moderately/well prepared to manage dysphagia. Only 22.0% of respondents recognized that tube feeding is unlikely to reduce risk of aspiration pneumonia whereas a slight majority understood that tube feeding would not likely prevent an uncomfortable death (50.2%), improve functional status (54.5%), or enhance quality of life (QOL) (63.2%). A majority (70.0%) was willing to consider recommending oral feeding despite high risk of aspiration. Logistic regression analyses indicated that those willing to consider this recommendation gave the most evidence-based responses to knowledge questions about tube feeding outcomes: aspiration pneumonia (odds ratio [OR]=1.75, 95% confidence interval [CI]=1.07-2.87), functional status (OR=1.43, 95% CI=1.0-2.06), QOL (OR=2.19, 95% CI=1.52-3.17), and prevent uncomfortable death (OR=1.97, 95% CI=1.37-2.88). Logistic regression analyses also indicated that those with more experience evaluating patients with dementia gave the most evidence-based response to two knowledge questions: aspiration pneumonia (OR=2.64, 95% CI=1.48-4.72) and prevent uncomfortable death (OR=2.03, 95% CI=1.35-3.05) whereas those with higher self-perceived preparedness in managing dysphagia in dementia had less knowledge in two areas: aspiration pneumonia (OR=0.57, 95% CI=0.38-0.84) and QOL (OR=0.72, 95% CI=0.51-1.01).

CONCLUSION

Misperceptions among SLPs about tube feeding in advanced dementia are common, especially in relation to risk of aspiration. Knowledge about tube feeding outcomes was positively associated with experience and inversely associated with self-perceived higher preparedness in evaluating patients with dementia.

Palliative care for patients with dementia in long-term care

Seventy percent of people in the United States who have dementia die in the nursing home. This article addresses the following topics on palliative care for patients with dementia in long-term care: (1) transitions of care, (2) infections, other comorbidities, and decisions on hospitalization, (3) prognostication, (4) the evidence for and against tube feeding, (5) discussing goals of care with families/surrogate decision makers, (6) types of palliative care programs, (7) pain assessment and management, and (8) optimizing function and quality of life for residents with advanced dementia.

Decision-making and outcomes of feeding tube insertion: a five-state study

OBJECTIVES

To examine family member's perceptions of decision-making and outcomes of feeding tubes.

DESIGN

Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life.

SETTING

Nursing homes, hospitals, and assisted living facilities.

PARTICIPANTS

Respondents whose relative had died from dementia in five states with varying feeding tube use.

MEASUREMENTS

Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems.

RESULTS

Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not.

CONCLUSION

Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review

BACKGROUND

Dementia is a progressive and incurable disease which presents many challenges to care providers, particularly in terms of end-of-life care. A palliative approach; that is an approach to care which seeks to ease burdensome symptoms without attempting curative treatment, has been suggested as the most appropriate framework for addressing the needs of these people.

OBJECTIVES

The overall objective was to establish best practice in relation to palliative care for people with advanced dementia in terms of effectiveness and appropriateness.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished English language studies, published between 1997 and 2009. A three-step search strategy was utilised in each component of this review.

CRITICAL APPRAISAL

Quantitative, qualitative and discursive text articles were included in this review. Articles were assessed for congruence to the review criteria and then critically appraised for quality using the appropriate JBI tool.

DATA COLLECTION AND ANALYSIS

Data were extracted using the appropriate JBI data extraction tool for each methodology. No quantitative meta-analysis was possible due to clinical and statistical heterogeneity. Qualitative synthesis was performed with the JBI QARI tool. Discursive textual synthesis was performed with the JBI NOTARI tool.

RESULTS

Quantitative studies recommended the use of do not resuscitate, do not hospitalise orders and other forms of advance directives to prevent interventions unwanted by the patient and/or their family. Feeding tubes and the use of intravenous antibiotics were not found to be an effective intervention. Interventions designed to treat the burdensome symptoms of advanced dementia (such as pain and agitation) were found to be of the most benefit to patients.Qualitative analysis found it distressing for families to discuss or plan for, a poor quality of life for their loved one during the process of dying. Decisions concerned with palliative treatment for the person with advanced dementia were found to be complicated by knowledge differences, lack of understanding of the disease trajectory of dementia, the unpredictable nature of dementia itself and religious and socio-economical issues. Textual analysis found that a palliative approach to end of life care in advanced dementia is both appropriate and effective in terms of benefit to patients and their significant others.Despite the large volume of data retrieved and analysed for this review, no studies examining the role of case-conferencing for managing the introduction of palliative care or managing a palliative approach met the inclusion criteria for this systematic review.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR FUTURE RESEARCH: There is a need for further studies in the area of palliation and advanced dementia, particularly high quality studies investigating palliative care case conferencing and other methods of arranging and planning end of life care for people with dementia.

CONCLUSION

There is some evidence to suggest that a palliative approach is both effective and appropriate for use with people who have advanced dementia. There is no evidence for or against the use of case-conferencing as a method of arranging care for people with advanced dementia.

Biological observation during the daytime of elderly patients with advanced dementia cared for with and without artificial nutrition by percutaneous endoscopic gastrostomy

AIM

To clarify the activity of demented patients cared for with and without artificial nutrition in a care facility, sequential biological observation was applied using electroencephalograms (EEG), electromyograms (EMG) and electro-oculograms (EOG).

METHODS

Awake and sleep patterns and spontaneous swallowing were measured during the daytime in 13 patients with advanced dementia who could orally intake meals (OR patients), and 13 patients with advanced dementia, who received artificial nutrition by percutaneous endoscopic gastrostomy (PEG patients).

RESULTS

The awake/sleep pattern fluctuated during daytime in OR and PEG patients, but a fully awake state was relatively preserved around meal times in OR patients. The number of spontaneous swallowing was small in PEG patients (0.1 ± 0.3/h), and the value correlated with the Barthel Index in OR patients.

CONCLUSION

Continuous recording of biological activity in demented patients could be informative in providing an overview of their activities. The present results disclosed that meal times were the limited periods keeping OR patients awake consistently, while there was no opportunity for such periods for PEG patients. The number of spontaneous swallowing was especially small in PEG patients, although low Mini-Mental State Examination and Barthel Index scores and poor awake state during daytime were considerable in those patients.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

Enteral nutrition in patients with dementia and stroke

PURPOSE OF REVIEW

Patients suffering from dementia or significant cognitive impairment (SCI) due to neurologic injury routinely receive percutaneous endoscopic gastrostomy (PEG) due to swallowing difficulty or lack of appetite. This review discusses current data and opinion regarding the risks and benefits of PEG in these populations.

RECENT FINDINGS

The current data regarding PEG placement in patients with dementia or SCI due to neurologic injury do not confirm either improvement or worsening of survival. Significant risk factors for poor prognosis after PEG include sex, hypoalbuminemia, age, chronic heart failure, and subtotal gastrectomy. Complications associated with enteral nutrition are minor and easily controlled when managed by a nutritional team. Alternative options for feeding elderly demented patients are available for family members considering PEG.

SUMMARY

In contrast to previously published data regarding worse clinical outcomes in the dementia and SCI populations receiving PEG, recent data suggest that clinical outcomes in this population are no different than in other patient populations receiving PEG. A prospective, randomized study is needed to ascertain whether PEG is appropriate and beneficial in the dementia/SCI populations.

Decision making near life's end: a prescription for change

Abstract The publication of SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) in 1995 identified major problems with decision making near the end of life. Since that time, palliative care has developed as a specialty and end-of-life communication has evolved. However, five problems in decision-making remain today: the need to discuss underlying health status with patients; the overburdening of patients and families with too many choices; lack of appreciation of the importance of symbolism in end-of-life care; confusion between cultural beliefs and scientific facts; and difficulties with making decisions because of rapid shifts by the medical team from advocating cure to comfort. Each of these issues is described.

Revisiting the Use of Percutaneous Endoscopic Gastrostomy Tubes in Patients with Advanced Dementia

Mr. Smith is an 85-year-old nursing home patient who has suffered from dementia for the past eight years. He has been bed bound and uncommunicative for the last six months. He was admitted with aspiration pneumonia three times in the past year. Over the last few months he has lost weight due to poor dietary intake and has developed a decubitus ulcer. Mr. Smith's family inquires about the advantages and disadvantages of the placement of a percutaneous endoscopic gastrostomy (PEG) tube to help improve his weight loss.