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Casas Deza D, Monzón Baez RM, Lamuela Calvo LJ, Betoré Glaria E, Montil Miguel E, Julián Gomara B, Vicente Lidón R. Complications and survival following percutaneous endoscopic gastrostomy tube placement. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38767020 DOI: 10.17235/reed.2024.10335/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is considered a safe and effective method for nutritional support in patients with malnutrition and swallowing impairment with an estimated survival of over two months. Some indications, such as advanced cognitive decline, contraindicate the technique. MATERIALS AND METHODS All patients who underwent PEG placement between January 2001 and May 2019 were included. Clinical data, indication, complications, and mortality were retrospectively analyzed. RESULTS A total of 648 patients (46.5% male, mean age 70±18.5 years) were included. The most common indications for PEG were advanced cognitive decline (31.5%) and cerebrovascular disease (18.8%). The mean follow-up was 12.07 months (IQR 3.27-34.73). 39.5% of patients experienced complications (systemic 17.9%, local 28.5%). The most frequent were bronchoaspiration (9.7%) and rupture/dysfunction (13.9%), respectively. The presence of early complications (HR 1.63 [1.20-2.21]) and age (HR 1.02 [1.01-1.02]) were associated with shorter survival time, while female sex was a protective factor (HR 0.78 [0.66-0.94]). CONCLUSIONS PEG is not without complications, with 39.5% of patients experiencing them. Patients with advanced dementia, male sex, older age, and systemic complications have lower survival following PEG placement.
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Vaughan DM, Lesandrini J. THE ETHICS OF PEG TUBE PLACEMENT IN A PATIENT WITH ADVANCED DEMENTIA. Gastroenterol Nurs 2023:00001610-990000000-00096. [PMID: 38150618 DOI: 10.1097/sga.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- David Michael Vaughan
- David Michael Vaughan, JD, LLM, MPH, is Clinical Ethics Fellow, Ethics Program, Wellstar Health System, Marietta, Georgia
- Jason Lesandrini, FACHE, LPEC, HEC-C, is Assistant Vice President Ethics, Advance Care Planning, and Spiritual Health, Ethics Program, Wellstar Health System, Marietta, Georgia
| | - Jason Lesandrini
- David Michael Vaughan, JD, LLM, MPH, is Clinical Ethics Fellow, Ethics Program, Wellstar Health System, Marietta, Georgia
- Jason Lesandrini, FACHE, LPEC, HEC-C, is Assistant Vice President Ethics, Advance Care Planning, and Spiritual Health, Ethics Program, Wellstar Health System, Marietta, Georgia
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Cheng H, Deng X, Li J, Tang Y, Yuan S, Huang X, Wang Z, Zhou F, Lyu J. Associations Between Dysphagia and Adverse Health Outcomes in Older Adults with Dementia in Intensive Care Units: A Retrospective Cohort Study. Clin Interv Aging 2023; 18:1233-1248. [PMID: 37554511 PMCID: PMC10405813 DOI: 10.2147/cia.s409828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/17/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Dysphagia is common in elderly patients with dementia and is one of the common clinical geriatric syndromes. It imposes a heavy burden on patients and their caregivers and is becoming an important public health problem. This study examined the association between dysphagia in older dementia patients in the ICU and the subsequent adverse health outcomes they experience. PATIENTS AND METHODS A retrospective analysis of adults (≥65 years) with dementia in ICUs of a Boston tertiary academic medical center was conducted. Using the International Classification of Diseases' Ninth and Tenth Revisions, dementia patients were identified. The study cohort comprised 1009 patients, median age 84.82 years, 56.6% female, predominantly White (72.9%). Patients were grouped based on swallowing function: dysphagia (n=282) and no-dysphagia (n=727). Dysphagia was identified via positive bedside swallowing screening. Primary outcomes were 90- and 180-day mortality, secondary outcomes included aspiration pneumonia, pressure injury, and delirium. Cohort characteristics were compared using the Wilcoxon rank-sum and chi-square tests. Dysphagia and outcomes correlations were examined via Kaplan-Meier survival analysis, Cox proportional-hazards regression models, logistic regression models, and subgroup analysis. RESULTS After adjusting for covariates, the results from multivariate Cox proportional-hazards regression indicated that dysphagia was significantly associated with increased 90-day (HR=1.36, 95% CI=1.07-1.73, E-value=1.78) and 180-day (HR=1.47, 95% CI=1.18-1.82, E-value=1.94) mortality; the multifactorial logistic regression results indicated that dysphagia was associated with significant increases in pressure injury (OR=1.58, 95% CI=1.11-2.23, E-value=1.83) and aspiration pneumonia occurrence (OR=4.04, 95% CI=2.72-6.01, E-value=7.54), but was not significantly associated with delirium prevalence (OR=1.27, 95% CI=0.93-1.74). CONCLUSION Dysphagia is likely to increase the risk of adverse health outcomes in older adults with dementia in ICU, and these adverse outcomes mostly include 90- and 180-day mortality, aspiration pneumonia, and pressure injury.
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Affiliation(s)
- Hongtao Cheng
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
- School of Nursing, Jinan University, Guangzhou, People’s Republic of China
| | - Xingwen Deng
- Department of Medical Information, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
| | - Jieyao Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
| | - Yonglan Tang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
- School of Nursing, Jinan University, Guangzhou, People’s Republic of China
| | - Shiqi Yuan
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
| | - Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
| | - Zichen Wang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, People’s Republic of China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, People’s Republic of China
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El Halabi M, Arwani R, Parkman HP. Dysphagia in Neurological Disorders. Semin Neurol 2023; 43:530-539. [PMID: 37579785 DOI: 10.1055/s-0043-1771458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Dysphagia is a common symptom in many neurologic disorders. Patients with oropharyngeal dysphagia present with difficulties when they start to swallow, often with coughing and choking; whereas patients with esophageal dysphagia describe the feeling that swallowed food stops in the chest. Chronic neurologic diseases such stroke, Parkinson's disease, or dementia often have dysphagia as a symptom, particularly oropharyngeal dysphagia, and the term "neurogenic dysphagia" is often used. A disruption of the sophisticated, integrated sensorimotor swallowing system is usually the main reason behind dysphagia. Dysphagia can be associated with aspiration leading to aspiration pneumonia, and chronic dysphagia can lead to weight loss and malnutrition. Patients with dysphagia, when accurately and promptly diagnosed through medical history, physical examination, and diagnostic tests, often can be treated and experience improved quality of life. The pathophysiological mechanisms behind dysphagia, its diagnosis, and potential treatments are discussed in this manuscript.
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Affiliation(s)
- Maan El Halabi
- Section of Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Remy Arwani
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Henry P Parkman
- GI Motility Laboratory, Section of Gastroenterology, Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
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Blanco Ramos B, Gómez Bellvert N. [Caregiver burden and reported quality of life in neurological patients with gastrostomy tubes.]. NUTR HOSP 2023. [PMID: 37154027 DOI: 10.20960/nh.04546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVE the aim of the study is to determine if the use of home enteral nutrition (HEN) by percutaneous endoscopic gastrostomy (PEG) reduces the burden on the caregiver and improves the patients' quality of life reported by the caregivers. MATERIAL AND METHODS a prospective, cross-sectional, descriptive, and observational study of a single cohort of 30 patients was conducted. RESULTS the results showed an improvement in nutritional status and analytical parameters. Fewer admissions (1.50 ± 0.90 vs 0.17 ± 0.38; p < 0.001) and hospital stays were reported at 3 months after gastrostomy (10.2 ± 8.02 days vs 0.27 ± 0.69 days; p < 0.001). The minutes spent by caregivers administering NEDs decreased after PEG placement by 28.5 minutes per feeding, which amounts to almost 150 minutes over a day and 5 feedings per day. In the Zarit questionnaire, there was a reduction of 13.5 points in the perception of overload. A total of 56.6 % of caregivers reported that quality of life had improved "quite a lot", compared to 6.7 % who reported little improvement, and 36.7 % who reported a lot of improvement. In the QoL-AD questionnaire, a higher score of 3.40 points was obtained. CONCLUSION the use of HEN by PEG tube reduces the time spent by the caregiver administering EN, which results in a reduced burden. In addition, the quality of life of patients reported by caregivers improved.
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Marlor DR, Taghlabi KM, Hierl AN, Braasch MC, Winfield RD. In-hospital, 30- and 90-day mortality in elderly trauma patients with operative feeding tubes. Am J Surg 2023; 225:758-763. [PMID: 36404168 DOI: 10.1016/j.amjsurg.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nutrition is essential in the treatment of elderly trauma patients (ETP). ETP experience dysphagia at rates six times higher than the non-trauma elderly population (NTEP) and are at increased risk for malnutrition. Operative feeding tube (OFT) placement is often used to aid with the nutritional management of ETP. Elderly patients experience higher rates of morbidity and mortality when compared to the general population, especially in the traumatic setting, with some data suggesting in-hospital mortality as high as 10%. However, the mortality rates and associated comorbidities associated with OFT in ETP are unknown. The purposes of this study were to establish the mortality rate in hospital as well as 30- and 90-days following discharge among elderly trauma patients (ETP) receiving OFT, and to assess factors associated with mortality within this population. METHODS A retrospective review of all trauma patients from a single Level I Trauma Center from 01/2010-09/2020 was conducted. Exclusion criteria were patients under 65 years of age or those with previously placed OFT. Demographics, comorbidities, injury mechanisms, injury severity scores (ISS), and OFT data were collected from the institutional trauma registry. Mortality data were obtained using the Social Security Death Index. Mortality at discharge, 30 days, and 90 days following discharge were the primary outcomes. Bivariate analysis was conducted to compare characteristics and comorbidities of patients alive and dead at the time points of interest. RESULTS There were 151 ETP who received OFT. Patients were largely male (67.5%), severely injured via a blunt mechanism (95%), and had a median age of 76 years. 11 (7.3%) experienced in-hospital mortality following feeding tube placement, 21 (13.9%) died within 30 days, and 31 (20.5%) within 90 days. Bivariate analysis demonstrated that ETP who died were more likely to have a history of dementia (p = 0.004), congestive heart failure (p = 0.014), and end-stage liver disease (p = 0.034). No other patient or injury factors were associated with mortality after OFT placement. CONCLUSION Mortality rates for ETP with OFT were higher than anticipated, yet favorable compared to recently reported data. Patients who died were more likely to have dementia, CHF, or ESLD than those who survived. The few comorbidities associated with mortality suggest that nearly all ETP who undergo OFT placement are at risk for mortality. Additionally, the data highlights the importance of early goals of care discussions for ETP and their loved ones when operative feeding tubes are being considered. LEVEL OF EVIDENCE Level III. STUDY TYPE Prognostic/Therapeutic/Diagnostic Test/Economic/Decision.
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Affiliation(s)
- Derek R Marlor
- University of Kansas Medical Center, Trauma, Surgical Critical Care and Acute Care Surgery, Kansas City, KS, USA.
| | - Khaled M Taghlabi
- University of Kansas Medical Center, Trauma, Surgical Critical Care and Acute Care Surgery, Kansas City, KS, USA.
| | | | | | - Robert D Winfield
- University of Kansas Medical Center, Trauma, Surgical Critical Care and Acute Care Surgery, Kansas City, KS, USA.
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Role of endoscopy on enteral feeding. Curr Opin Gastroenterol 2022; 38:461-466. [PMID: 35881958 DOI: 10.1097/mog.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Rajan A, Wangrattanapranee P, Kessler J, Kidambi TD, Tabibian JH. Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices. World J Gastrointest Surg 2022; 14:286-303. [PMID: 35664365 PMCID: PMC9131834 DOI: 10.4240/wjgs.v14.i4.286] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/09/2022] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.
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Affiliation(s)
- Anand Rajan
- Department ofGastroenterology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
- Department ofGastroenterology, City of Hope Medical Center, Duarte, CA 91010, United States
| | | | - Jonathan Kessler
- Department ofInterventional Radiology, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Trilokesh Dey Kidambi
- Department ofGastroenterology, City of Hope Medical Center, Duarte, CA 91010, United States
| | - James H Tabibian
- Department ofGastroenterology, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
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Navia RO, Constantine LA. Palliative care for patients with advanced dementia. Nursing 2022; 52:19-26. [PMID: 35196277 DOI: 10.1097/01.nurse.0000820024.83629.ee] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older adults globally. Its final stages are complicated by a multitude of problems that can cause immense suffering. This article explores the interconnection between advanced dementia and palliative care and the role of nurses in providing end-of-life care for these patients.
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Affiliation(s)
- R Osvaldo Navia
- R. Osvaldo Navia is the chief of Geriatrics, Palliative Medicine and Hospice; the Grace Kinney Mead Chair of Geriatrics; an attending at the Rockefeller Neuroscience Institute; and an assistant professor at West Virginia University School of Medicine
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Ethical decision-making process for percutaneous endoscopic gastrostomy in patients with dysphagia. Eur Geriatr Med 2021; 12:1305-1306. [PMID: 34272661 DOI: 10.1007/s41999-021-00540-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
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Arvanitakis M, Gkolfakis P, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:81-92. [PMID: 33260229 DOI: 10.1055/a-1303-7449] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, The Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital and University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Dietrich CG, Schoppmeyer K. Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy? World J Gastroenterol 2020; 26:2464-2471. [PMID: 32523304 PMCID: PMC7265142 DOI: 10.3748/wjg.v26.i20.2464] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/30/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023] Open
Abstract
Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.
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Affiliation(s)
- Christoph G Dietrich
- Medical Clinic, Bethlehem-Gesundheitszentrum Stolberg/Rhld., Stolberg D-52222, Germany
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van Bruchem-Visser RL, van Dijk G, Mattace Raso F, de Beaufort I. Requests for futile treatments: what mechanisms play a role? Results of a qualitative study among Dutch physicians. BMJ Open 2020; 10:e035675. [PMID: 32350017 PMCID: PMC7213846 DOI: 10.1136/bmjopen-2019-035675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Overtreatment is increasingly seen as a challenge in clinical practice and can lead to unnecessary interventions, poor healthcare outcomes and increasing costs. However, little is known as to what exactly causes overtreatment. In 2015, the Royal Dutch Medical Association (RDMA) attempted to address this problem and distinguished several mechanisms that were thought to drive overtreatment. In 14 qualitative interviews among Dutch physicians, we investigated which mechanisms played a role in decision-making and whether all mechanisms were considered equally important. DESIGN We asked physicians to present a case from personal experience, in which the patient or family requested continuing treatment against the advice of the physician. PARTICIPANTS Fourteen physicians from five different medical areas agreed to participate. SETTING Interviews were held face-to-face at the workplace of the physician. RESULTS Three closely related mechanisms were mentioned most frequently as drivers of overtreatment, as perceived by the physician: 'death is not a common topic of conversation', ''never give up' is the default attitude in our society' and 'patients' culture and outlook on life influences their perception of death'. The mechanism 'medical view taking priority' was mentioned to be an inhibitor of overtreatment. CONCLUSIONS Of the 15 mechanisms described by the report of the Steering Committee of the RDMA, not all mechanisms were mentioned as driving overtreatment. Three mechanisms were mentioned most as being a driver of overtreatment ('death is not a common topic of conversation'; ''never give up' is the default attitude in our society'' and 'patients' culture and outlook on life influences their perception of death'), some played no role at all, and others were considered to be inhibitors of overtreatment, especially the mechanism 'medical view taking priority'.
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Affiliation(s)
| | - Gert van Dijk
- Medical Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Francesco Mattace Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Inez de Beaufort
- Medical Ethics and Philosophy of Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
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