Barriers to Limiting the Practice of Feeding Tube Placement in Advanced Dementia

Factors Associated with Differences in Physicians' Attitudes toward Percutaneous Endoscopic Gastrostomy Feeding in Older Adults Receiving End-of-Life Care in Japan: A Cross-Sectional Study

Background

Although percutaneous endoscopic gastrostomy (PEG) placement is still widely practiced in Japan, studies from Western countries report that it is less beneficial for patients in end-of-life care with cognitive decline. Decisions regarding PEG placement are largely influenced by physician judgment.

Objectives

The aim of this study was to investigate the background and perceptions of Japanese physicians regarding PEG for older adults in end-of-life care and to identify the factors associated with differences in physician judgment regarding PEG.

Design

The study employed a cross-sectional design.

Setting/Subjects

A questionnaire on PEG for older adults in end-of-life care was sent to Japanese physicians. Logistic regression analysis was used to calculate the odds ratios (ORs) and confidence intervals (CIs) of the association between PEG recommendations and each factor.

Results

PEG placement was advised for bedridden patients and older adults with cognitive decline by 26% of the physicians who responded to the survey. Differences in physician perceptions of PEG feeding were associated with the recommendation for PEG, benefits of preventing aspiration pneumonia (OR: 4.9; 95% CI: 3.1-8.2), impact on post-discharge accommodation decisions (OR: 6.1; 95% CI: 1.9-30.9), and hesitancy to recommend a PEG placement (OR: 1.9; 95% CI: 1.3-4.5). Working in a facility with PEG placement (OR: 2.0; 95% CI: 1.2-3.5) was an associated background factor.

Conclusions

Differences in Japanese physicians' attitudes toward using PEG feeding for older adults in end-of-life care were significantly associated with differences in their perceptions of the impact of PEG feeding and working in a facility with PEG placement.

"A good death but there was all this tension around"- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

BACKGROUND

End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia.

METHODS

Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis.

RESULTS

20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding.

CONCLUSION

Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident's terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review

BACKGROUND

This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved.

METHODS

We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497.

RESULTS

Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation.

CONCLUSIONS

The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.

Attitude and experience of neurologists towards percutaneous endoscopic gastrostomy: an Egyptian study

Background

Dysphagia is a common symptom among various neurological diseases. Guidelines recommend gastrostomy insertion for prolonged dysphagia with lower rate of intervention failure encountered with percutaneous endoscopic gastrostomy (PEG) as compared to nasogastric tube insertion.

Methods

Neurology consultants only were included and completed a self-administered questionnaire concerning their practice backgrounds and previous experience with PEG feeding during their practice.

Results

Ninety-eight percent stated that they would recommend PEG for patients with prolonged need of nasogastric feeding. However, only 88% actually referred patients to perform PEG, with the cerebrovascular disorders being the most common cases to be referred. The main barriers the surveyed neurologists faced were family resistance and financial reasons (53.5%). Interestingly, younger neurologists practicing for less than 15 years referred patient to perform PEG significantly more frequent than older ones (p = 0.01). About 18% of our sample confirmed the lack of sufficient knowledge about the benefits of PEG feeding, and only 22% previously attended scientific sessions about the benefits and indications of PEG.

Conclusion

Based on our study, we recommend that PEG should be more encouraged in indicated neurological cases. Scientific sessions targeting neurologists and public awareness about the benefits of PEG and its relatively infrequent complications are highly demanded.

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

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.

Percutaneous endoscopic gastrostomy in older patients with and without dementia: Survival and ethical considerations

BACKGROUND AND AIM

Notwithstanding multiple recommendations in guidelines, percutaneous endoscopic gastrostomy (PEG)-tube placement is still performed in patients with dementia. In this study, we aim to investigate survival in patients with and without dementia after PEG-tube placement.

METHODS

We conducted a retrospective multicenter study in four different hospitals in the Netherlands. Furthermore, we explored the ethical considerations that may play a role in the decision whether or not to insert a PEG tube in a patient with dementia.

RESULTS

Three-hundred-and-three patients were included, mean age of 77.4 years. Forty-two (13.9%) patients had dementia. Short-term complications did not differ between patients with and without cognitive disorders (P 0.224). However, patients with dementia survived significantly shorter after PEG placement than did patients without dementia. Adjusted for age and sex, patients with dementia had a 49% increased risk of mortality (hazard ratio 1.49, 95% confidence interval 1.01-2.19). In our exploratory literature search, we found that several ethical concerns and considerations play a role in the decision process of PEG placement. These considerations are both medical and nonmedical and include beliefs regarding the benefits of a PEG tube, a lack of knowledge about the natural course of dementia in both professionals and family of patients, and a fear of letting a patient die hungry.

CONCLUSIONS

Patients with dementia had higher mortality rates after PEG placement than patients without dementia. Although multiple ethical concerns and considerations play a role, insertion of a PEG tube in patients with dementia is not appropriate.

Practitioner Knowledge, Personal Values, and Work Setting Influence Registered Dietitians' Feeding Tube Recommendations for Patients With Advanced Dementia

BACKGROUND

Current guidelines discourage tube-feeding older adults with advanced dementia (AD), as this practice does not improve nutrition status or survival and decreases quality of life in these patients. Because registered dietitians (RDs) often provide feeding recommendations for patients with AD, this study aimed to identify factors that influenced RDs' feeding tube recommendations for older adults with AD.

METHODS

A random sample of RDs who work with older adults in the United States completed a validated, electronic survey. Logistic regression analysis was used to identify factors related to the likelihood of RDs recommending a feeding tube for patients with AD. Independent variables included participant demographics and the 6 subscales of the Attitudes Toward Tube-Feeding in Advanced Dementia Questionnaire, which measured individual and environmental influences on RDs' recommendations.

RESULTS

Among the 662 RDs who responded, 72.2% were unlikely to recommend a feeding tube in patients with AD, and 15.4% were likely to do so (with the remaining being "neutral"). Factors associated with avoiding recommending a feeding tube include significantly higher total knowledge [odds ratio (OR) = 1.47, 95% CI (1.30, 1.66)] and personal values scores [OR = 7.51, 95% CI (3.96, 14.24)] and employment in long-term care settings [OR 3.29, 95% CI (1.38, 7.80)].

CONCLUSION

In this survey, most RDs were likely to make recommendations that are consistent with current guidelines for tube feeding patients with AD. RDs who work outside the long-term care setting may benefit from additional training. Future research is needed to understand how personal values may influence recommendations.

The Attitudes Toward Tube-Feeding in Advanced Dementia (ATT-FAD) Questionnaire: A Valid and Reliable Tool

Registered Dietitians (RDs) should participate in interdisciplinary feeding discussions for patients with advanced dementia, but research on how RDs make such feeding recommendations is scarce. This study developed and validated a theory-based questionnaire to assess the knowledge, beliefs, and attitudes of RDs regarding feeding tube use among older adults with advanced dementia. The instrument was drafted based on the Social Ecological Model, and face and content validity were established through an expert panel review. Pilot testing with 70 RDs provided an initial measure of internal consistency reliability and reduced the number of items in the survey. Efficacy testing with 662 RDs allowed for a second analysis of internal consistency reliability and eliminated additional items. Construct validity was then established using validation by extreme groups and exploratory factor analysis, yielding six subscales, each with adequate internal consistency and test-retest correlation coefficients: (I) Total Knowledge, (II) Knowledge Self-Efficacy, (III) Religion/Spirituality/Culture, (IV) Personal Values, (V) Perceived Organization and Training, and (VI) Perceived Policy. The survey, based on the Social Ecological Model, was deemed a valid and reliable tool to assess RDs' knowledge and attitudes regarding feeding tube use among older adults with advanced dementia.

Staff Perspectives of Barriers to Access and Delivery of Palliative Care for Persons With Dementia in Long-Term Care

Dementia is a syndrome that is progressive, degenerative, and terminal. The palliative care philosophy aims to maximize quality of life for the dying individual and is both beneficial for and underused with persons dying with dementia.

OBJECTIVES

The purpose of this study was to investigate the experiences of long-term care staff delivering palliative care to individuals with dementia to determine how care was delivered, to learn which guidelines were used, and whether policies affected the delivery of palliative care.

METHODS

Twenty-two staff participants were interviewed. Their experiences were interpreted using phenomenological methodology.

RESULTS

Findings yielded 3 key themes: confusion, resource shortages, and communication difficulties.

CONCLUSION

Implications for practice include clarification of terminology surrounding palliative care, education of families about dementia and palliative care, better resource management, and the need to address when palliative care best fits within the dementia process.

An Iceberg Phenomenon in Dementia: Pain

BACKGROUND

Pain is one of the most frequent symptoms in older adults. It severely impairs quality of life, increases delirium risk, and may lead to progression of dementia. Assessment of pain performed by taking anamnesis from the patient is not reliable in patients with dementia due to cooperation and communication problems. The aim of this study was to assess pain and its consequences in patients with dementia.

METHODS

Seventy-five nursing home residents with dementia were enrolled. After comprehensive geriatric assessment, presence of pain was asked to patients, and Pain Assessment in Advanced Dementia (PAINAD), Discomfort Scale for Dementia of the Alzheimer's Type (DS-DAT), Pain Assessment for the Dementing Elderly (PADE), Wong-Baker Faces Pain Rating Scale, and Numeric Rating Scale tests were performed.

RESULTS

Mean age was 81.1 (7.0), and 46.7% (n = 35) were female. Thirty-two percent of the patients were at early stage, 24% at moderate stage, and 44% at severe stage. Although the number of patients declaring pain was lower in moderate and severe stage, scores of PADE, PAINAD, and DS-DAT were significantly higher in severe stage showing the presence of pain ( P < .001). Furthermore, scores of PADE, PAINAD, and DS-DAT were negatively correlated with comprehensive geriatric assessment test scores.

CONCLUSION

These results demonstrate that pain is not rare in patients with dementia, but they are not usually capable of expressing it, especially in the severe stage. Therefore, objective pain assessment scales developed for patients with dementia should be routinely used and management of pain should be done regarding the association of pain with other geriatric syndromes.

Doctors' Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia

BACKGROUND

The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect.

METHODS

A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia.

RESULTS

201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%).

CONCLUSION

We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.

Is parenteral hydration beneficial in terminally ill cancer patients?

INTRODUCTION

It is common for terminally ill patients to have a reduced fluid intake, which often results in a need for more medical support. However, it is not clear if this measure has a real clinical impact.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data from primary studies and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified four systematic reviews including 51 studies overall, from which three were randomized trials. We concluded the administration of parenteral hydration might make little or no difference in terms of survival and quality of life in terminally ill cancer patients, and that it is not clear whether it has any other benefit because the certainty of the evidence is very low.

Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review

Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.

Diagnostic Assessment and Management of Dysphagia in Patients with Alzheimer's Disease

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.

The Role of Intravenous Fluids and Enteral or Parenteral Nutrition in Patients with Life-limiting Illness

The decision of whether or not to use artificial nutrition or hydration is one with which many health care providers, patients, and families struggle. These decisions are particularly challenging in the setting of life-limiting illness, which is often associated with a prolonged decline because of medical advances in these patient populations. A patient-centered and family-centered approach helps to attain high-quality care in this special population.

Preparedness for End of Life-a Survey of Jerusalem District Nursing Homes

OBJECTIVES

To evaluate the quality of end-of-life (EOL) care in nursing homes.

DESIGN

Survey and semistructured interviews.

SETTING

Jerusalem district nursing homes.

PARTICIPANTS

Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207).

MEASUREMENTS

Qualitative analysis of semistructured interviews and statistical analysis of questionnaires.

RESULTS

Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family's preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents.

CONCLUSION

Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement.

Symptoms and treatment when death is expected in dementia patients in long-term care facilities

BACKGROUND

Although dementia at the end of life is increasingly being studied, we lack prospective observational data on dying patients. In this study symptoms were observed in patients with dementia in the last days of life.

METHODS

When the elderly care physicians in two Dutch nursing homes expected death within one week, symptoms of (dis)comfort, pain and suffering were observed twice daily. For this the Pain Assessment in Advanced Dementia (PAINAD; range 0-10), Discomfort Scale-Dementia of Alzheimer Type (DS-DAT; range 0-27), End-Of-Life in Dementia-Comfort Assessment in Dying (EOLD-CAD; range 14-42) and an adapted version of the Mini-Suffering State Examination (MSSE; range 0-9), were used. Information on care, medical treatment and treatment decisions were also collected.

RESULTS

Twenty-four participants (median age 91 years; 23 females), were observed several times (mean of 4.3 observations (SD 2.6)), until they died. Most participants (n = 15) died from dehydration/cachexia and passed away quietly (n = 22). The mean PAINAD score was 1.0 (SD 1.7), DS-DAT 7.0 (SD 2.1), EOLD-CAD 35.1 (SD 1.7), and MSSE 2.0 (SD 1.7). All participants received morphine, six received antibiotics, and rehydration was prescribed once.

CONCLUSION

In these patients with dementia and expected death, a low symptom burden was observed with validated instruments, also in dehydrated patients without aggressive treatment. A good death is possible, but might be enhanced if the symptom burden is regularly assessed with validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.

Challenges in efficacy research: the case of feeding alternatives in patients with dementia

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.

Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia

CONTEXT

The best evidence suggests that feeding tubes are ineffective in persons with advanced dementia. Little is known about their health care costs.

OBJECTIVES

To estimate Medicare costs attributable to inpatient care among nursing home (NH) residents with advanced dementia during the year following the placement of a percutaneous endoscopic gastrostomy (PEG) tube during an index hospitalization.

METHODS

Medicare claims (1999-2009) and Minimum Data Set data (1999-2009) were used to estimate Medicare costs attributable to inpatient care among NH residents with advanced dementia during the year following the placement of a PEG tube and compared with those who did not get a PEG tube. The study used a 3:1 propensity-matched cohort design.

RESULTS

Matched residents with (n=1924, 68.9% female, 28.8% African American, average age 83.1 years) and without (weighted n=1924, unique n=4337) PEG insertion showed comparable sociodemographic characteristics, similar rates of feeding tube risk factors, and similar mortality (51.9% 180 day mortality among those with a feeding tube vs. 49.8% among those without a feeding tube, P=0.11). One year hospital costs were $2224 higher in NH residents with a feeding tube ($10,191 vs. $7967, 95% CI of difference=$1514, $2933), with those with a feeding tube likely to spend more time in an intensive care unit (1.92 vs. 1.29 days, 95% CI of difference=0.34, 0.92 days).

CONCLUSION

In an analysis controlling for selection bias, PEG tube insertion is associated with a small but significant increase in annual inpatient health care costs, as well as in hospital and intensive care unit days, postinsertion.

Percutaneous endoscopic gastrostomy (PEG) tubes are placed in elderly adults in Japan with advanced dementia regardless of expectation of improvement in quality of life

BACKGROUND

The Japan Geriatrics Society published a guideline on the decision-making process for health care for the elderly in June 2012, noting that withholding or withdrawing feeding tubes are treatment options that should be discussed during the decision-making process. Arguments against the guideline posit that the insertion of a percutaneous endoscopic gastrostomy (PEG) tube feeding may improve quality of life (QOL) for elderly adults and their relatives.

OBJECTIVES

The aim of the present study was to explore (a) expected outcomes with PEG tube placement and (b) outcomes from PEG tube feeding in long-term care settings among elderly adults with advanced dementia in Japan.

DESIGN

This study was conducted using a cross-sectional study design.

SETTING

A total of 381 hospitals and 985 long-term care facilities provided sets of completed questionnaires.

PARTICIPANTS

There were 1 199 hospital patients and 2 160 long-term care patients aged 65 years or older with PEG tube placement included in the analysis.

MEASUREMENTS

The nurses or physicians at each hospital provided information on the level of dementia at the time of PEG tube placement and on the expected outcomes of PEG tube feeding for elderly hospital patients. The nurses or other direct care workers at each facility provided information on the level of dementia and outcomes from PEG tube feeding for the long-term care patients.

RESULTS

In the hospital patient group, 62.9% of patients had advanced dementia. PEG tube feeding was expected to prolong survival for 51.1% of hospital patients with advanced dementia. Improved QOL was expected for 39.1% of them. In the long-term care patient group, 61.7% of patients had advanced dementia. The rate of patients enjoying their own lives was lower in long-term care patients who had advanced dementia (4.2%) than in the other patients (16.4%). Approximately 60% of relatives reported satisfaction with the QOL of the patients, both in the long-term care patients with advanced dementia and the other patients.

CONCLUSION

Our results question the assumption that PEG tube feeding may improve QOL among elderly adults with advanced dementia. The national health policy should explore an approach to help patients, relatives, and practitioners make decisions about feeding options.

Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians' religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.

How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review

BACKGROUND

Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity.

METHODS AND FINDINGS

We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles.

CONCLUSIONS

When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.

Diagnosis and management of Alzheimer's disease: past, present and future ethical issues

There is great interest in the ethical issues associated with Alzheimer's disease (AD) and related dementias given the prevalence of AD and the evolving neuroscience landscape in matters of diagnoses and therapeutics. Much of the ethics discussion arises in the tension between the principle of not doing harm (principle of non-maleficence) in this vulnerable population and the development of effective treatments (principle of beneficence). Autonomy and capacity issues are also numerous, wide-ranging, and concern (1) day to day affairs such as driving safely and spending money wisely, (2) life-time events such as designating a legal representative in case of incapacity, making a will, (3) consenting to treatment and diagnostic procedures, (4) participating in research. The latter issue is particularly thorny and illustrates well the complexity of tackling concerns related to capacity. The impetus to protect AD patients has partly led to ethics regulation and policies making research on inapt patients more difficult because of stringent requirements for signed informed consent or for showing the value of the research to this specific patient population. New issues are arising that relate to earlier diagnosis using biomarkers and (possibly soon) the use of drugs that modify disease progression. We here summarize and discuss the different ethical issues associated with AD from a historical perspective, with emphasis on diagnostic and treatments issues.

Do patients with advanced cognitive impairment admitted to hospitals with higher rates of feeding tube insertion have improved survival?

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.

End-of-life care for patients with dementia in the United States: institutional realities

Few are satisfied with end-of-life care in the United States. For families and friends of people with dementia, end-of-life care is particularly frustrating. Providing better end-of-life care to people with dementia is urgent because the prevalence of the disease is increasing rapidly. Dementia is currently the seventh leading cause of death in the United States and fifth leading cause of death among people aged 65 years and older. By 2050, there will be around 19 million people with Alzheimer's disease. This article reviews ethical and policy challenges associated with providing end-of-life care for people with dementia in the United States. I explain how disagreements about the meaning of futility lead to poor care for people with dementia. Most people agree that we should not provide care that is futile, but there is little agreement about how futility should be defined. US policies and politics clearly tip the balance in the direction of treatment, even in the face of strong evidence that such care does more harm than good. Although we may never reach a consensus, it is important to address these questions and think about how to develop policies that respect the different values.

Feeding tubes and the prevention or healing of pressure ulcers

BACKGROUND

The evidence regarding the use of feeding tubes in persons with advanced dementia to prevent or heal pressure ulcers is conflicting. Using national data, we set out to determine whether percutaneous endoscopic gastrostomy (PEG) tubes prevent or help heal pressure ulcers in nursing home (NH) residents with advanced cognitive impairment (ACI).

METHODS

A propensity-matched cohort study of NH residents with ACI and recent need for assistance in eating was conducted by matching each NH resident who had a feeding tube inserted during a hospitalization to 3 without a PEG tube inserted. Using the Minimum Data Set (MDS), we examined 2 outcomes: first, whether residents without a pressure ulcer developed a stage 2 or higher pressure ulcer (n = 1124 with PEG insertion); and second, whether NH residents with a pressure ulcer (n = 461) experienced improvement of the pressure ulcer by their first posthospitalization MDS assessment (mean [SD] time between evaluations, 24.6 [32.7] days).

RESULTS

Matched residents with and without a PEG insertion showed comparable sociodemographic characteristic, rates of feeding tube risk factors, and mortality. Adjusted for risk factors, hospitalized NH residents receiving a PEG tube were 2.27 times more likely to develop a new pressure ulcer (95% CI, 1.95-2.65). Conversely, those with a pressure ulcer were less likely to have the ulcer heal when they had a PEG tube inserted (OR 0.70 [95% CI, 0.55-0.89]).

CONCLUSIONS

Feeding tubes are not associated with prevention or improved healing of a pressure ulcer. Rather, our findings suggest that the use of PEG tube is associated with increased risk of pressure ulcers among NH residents with ACI.

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.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy

INTRODUCTION

The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation.

METHODS

For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition.

RESULTS

The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context.

DISCUSSION

Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Perspectives of community members regarding tube feeding in patients with end-stage dementia: findings from African-American and Caucasian focus groups

Research has demonstrated that placement of permanent feeding tubes to provide artificial nutrition is more common among non-white populations, but there is a scarcity of research regarding why those differences may exist. The purpose of this study is to describe and understand community members' attitudes toward tube feeding and end-of-life decision-making. Four focus groups were convened in Greenville, NC. The 28 focus group participants were 11 African American and 17 Caucasian community members between ages 51 and 81. Two focus groups were held with Caucasian participants and two with African-American participants. Focus groups were recorded and transcribed, and qualitative analysis was performed using NVivo software. Seven themes resulted from the analysis of the transcripts. They included: "A feeding tube is," "Food is important," "They want to do the right thing," "To make a rational decision," "There are worse things than death," "There's a lot of good things," "It's out of my hands." There were more commonalities than differences in the views of African Americans and Caucasians on perspectives on tube feeding and elders with dementia. An unexpected emphasis was placed on the importance of food as a symbol of caring. Families tend to be oriented toward personal fidelity to the elder and the symbolic role of feeding in fulfilling that fidelity.

Effect of physician education and patient counseling on inpatient nonsurgical percutaneous feeding tube placement rate, indications, and outcome

BACKGROUND

The decision to place a percutaneous feeding tube (PFT) in patients who are at the end of life is multidimensional and often complicated. We assessed the effect of physician education and counseling for patients and their surrogates on inpatient nonsurgical (endoscopic and radiologic) PFT placement rates, indications, complications, and mortality.

METHODS

In a pre-paid group practice, a geriatrician initiated a program of physician education and patient/surrogate counseling on the ethical and nutritional aspects of long-term enteral feeding. We compared rates of nonsurgical PFT placement (excluding those for cancer therapy or gastric decompression), indications, complications, and short- and long-term mortality in adult inpatients before (2004) and after (2005) the program.

RESULTS

In 2004 and 2005, 115 and 60 inpatients underwent PFT placement, respectively. The annual number of hospital admissions was similar, but the rate of PFT placement declined (0.80% vs. 0.44%, P < 0.0001). The indications were cerebrovascular accident (42 [37%] versus 22 [37%]), dementia (15 [13%] versus 3 [5%]), other neurological disease (28 [24%] versus 16 [26%]), and miscellaneous disease (30 [26%] versus 19 [32%]); P > 0.05. Severe infectious complications occurred in 4 (3%) versus 0 (0%) patients, P > 0.05. Mortality (2004 versus 2005) at 30 days (23 [20%] versus 11 [18%]), 1 year (62 [54%] versus 29 [48%]) and 2 years (72 [63%] versus 31 [52%]) was similar, P > 0.05.

CONCLUSION

A pilot program of educating referring physicians and counseling patients and their surrogates reduced the rate of inpatient PFT placement by nearly 50%. Indications, severe complications and short- and long-term mortality remained unchanged.

Nurses' perspectives on feeding decisions for nursing home residents with advanced dementia

AIM

To develop a broad understanding of nursing beliefs, knowledge and roles in feeding decisions for nursing home residents with advanced dementia.

BACKGROUND

Concern is growing about the common use of feeding tubes in nursing home residents with advanced dementia. Nurses can play an important role in providing information and guiding family members through difficult feeding decisions. Little is known about nurses' perspectives on feeding decisions.

DESIGN

Qualitative descriptive.

METHODS

In-depth semi-structured interviews of 11 licensed nurses who were experienced in caring for nursing home residents with dementia.

RESULTS

Analysis of the interview transcripts revealed three themes: insufficient empirical information, ambiguous role in feeding decisions and uncertainty about moral agency in decisions about the placement of feeding tubes.

CONCLUSIONS

Despite views that family members would benefit from guidance in decisions regarding the placement of feeding tubes, nurses were, nevertheless, reluctant to become involved in these difficult decisions.

RELEVANCE TO CLINICAL PRACTICE

If nurses are to guide family members in decisions about the use of feeding tubes, they need more education about evidence-based practice as well as support in exercising their nursing responsibilities.

Physicians' expectations of benefit from tube feeding

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.

Natural history of feeding-tube use in nursing home residents with advanced dementia

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.

Percutaneous endoscopic gastrostomy in the dementia patient: helpful or hindering?

Percutaneous endoscopic gastrostomy (PEG) is a common technique performed worldwide. Recently, the use of PEG in the dementia patient with dysphagia for nutrition support has been called into question. Some reviews have reported no improvement in survival with PEG tubes in this population. Higaki and colleagues now present a large review of PEG tube placement in patients with dementia, which demonstrates a similar survival rate in patients without dementia receiving PEG tubes. The question of the utility of PEG tube placement for nutrition support in the dementia population requires an organized, prospective analysis to concretely answer the question.

Feeding alternatives in patients with dementia: examining the evidence

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.

Tube feeding in dementia: how incentives undermine health care quality and patient safety

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.

PEG-Ernährung bei fortgeschrittener Demenz

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient's will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.

Satisfaction with end-of-life care for nursing home residents with advanced dementia

OBJECTIVES

To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia.

DESIGN

Cross-sectional study.

SETTING

Thirteen NHs in Boston.

PARTICIPANTS

One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs. MASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10-40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score.

RESULTS

The mean ages+/-standard deviation of the 148 residents and HCPs were 85.0+/-8.1 and 59.1+/-11.7, respectively. The mean SWC-EOLD score was 31.0+/-4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16-3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02-0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25-2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46-5.25, P=.02).

CONCLUSION

Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia.

Artificial nutrition and hydration at the end of life: Ethics and evidence

The case of Terri Schiavo resulted in substantial media attention about the use of artificial nutrition and hydration (ANH) especially by percutaneous endoscopic gastrostomy (PEG). In this article, I review ethical and legal principles governing decisions to choose or forgo ANH at the end of life, including issues of autonomy and decision-making capacity, similarities and differences between ANH and other medical treatments, the role of proxies when patients lack decision-making capacity, and the equivalence of withholding and withdrawing treatment. Evidence for palliative or life-sustaining benefits for ANH are reviewed in three disease processes: amyotrophic lateral sclerosis (ALS), cancer, and dementias, including Alzheimer's disease. Although more recent studies suggest a possible palliative role for ANH in ALS and terminal cancer, feeding tubes do not appear to prolong survival or increase comfort in advanced dementia of the Alzheimer's type.