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Feeding Tubes More Often Placed in Dementia Patients at For-Profit, Larger Hospitals

ARTICLE IN BRIEF

A new study reporting that higher insertion rates for feeding tubes were observed for nursing home residents with advanced cognitive impairment at for-profit compared to government-owned hospitals elicits discussion about neurologists' role in these types of end-of-life care decisions.

EDITOR'S NOTE

NEUROLOGY TODAYASSOCIATE EDITOR ROBERT H. HOLLOWAY, MD, MPH, COMMENTS ON “HOSPITAL CHARACTERISTICS ASSOCIATED WITH FEEDING TUBE PLACEMENT IN NURSING HOME RESIDENTS WITH ADVANCED COGNITIVE IMPAIRMENT:”

Widespread variations in clinical practice have been known to exist for decades. When researchers look for them they always find them — whether they pertain to prescribing medications (for example, cholinesterase inhibitors), performing procedures (such as carotid endarterectomy and carotid artery stenting), or deciding to admit to hospitals and intensive care units. Reducing unwarranted variations is a central tenet of President Obama's strategy for health care reform and behind the influx of research dollars targeted for comparative effectiveness research. But every once in a while, a study is published that more than reminds us of its ubiquity – it makes us cringe.

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DR. ROBERT H. HOLLOWAY

The Feb. 10 study in the Journal of American Medical Association, “Hospital Characteristics Associated with Feeding Tube Placement in Nursing Home Residents with Advanced Cognitive Impairment” showed that among nursing home residents with advanced dementia admitted to acute care hospitals, the insertion of a feeding-tube was associated with for-profit ownership, larger hospital size, and greater intensive care unit use (even after controlling for known patient characteristics). These findings suggest that factors other than informed patient choice might be influencing a decision that most find deeply personal and alert us to the potential vulnerabilities of being patients ourselves.

Unraveling the reasons behind this association will require us to confront some uncomfortable aspects of health care delivery and practice. Is this the “invisible hand” of Adam Smith? Are we sufficiently sensitive to our patient's spiritual needs? Do we communicate equally effectively across cultures and ethnicities? As neurologists caring for patients with advancing dementia this study reminds us of the importance of assisting patients and families with timely advance care planning to potentially reduce unnecessary procedures. It also underscores the need to be aware that there are other factors besides shared-decision making at the bedside with our patients and families that might be shaping the choices we make.

The likelihood that a nursing home patient with advanced dementia will receive a feeding tube during a hospitalization varies dramatically depending on the hospital's characteristics, a national study of Medicare claims has found.

The feeding-tube placement rates at 2,797 hospitals varied from a low of zero to a high of 38.9 per 100 admissions, with the mean rate dipping from 7.9 in the year 2000 to 6.2 in 2009, according to the Feb. 10 study in the Journal of the American Medical Association.

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DR. JASON H. T. KARLAWISH: “Tomorrow in your clinic, when you see that patient with mild Alzheimer disease, you can engage the patient and family about how we die of the disease and what to expect. Among the cluster of events in the terminal stage of Alzheimer disease are difficulties swallowing and a lack of drive to eat.”

Higher insertion rates were observed at for-profit compared to government-owned hospitals (8.5 vs. 5.5; adjusted odds ratio [AOR], 1.33). Likewise, larger hospitals, with more than 310 beds, had higher rates than smaller hospitals, with fewer than 101 beds (8.0 vs. 4.3; AOR, 1.48). Insertion rates were also higher in hospitals that had higher levels of intensive care unit use in the last six months of life (highest vs. lowest decile: 10.1 vs 2.9; AOR, 2.60). The differences persisted after controlling for patient characteristics.

The results indicate that neurologists could do a better job of educating patients and families at the early stage of dementia about the disease's natural course, and the lack of evidence supporting a survival benefit for feeding tubes in the final stages of the disease's progression, bioethicists and neurologists agreed.

“Tomorrow in your clinic, when you see that patient with mild Alzheimer disease, you can engage the patient and family about how we die of the disease and what to expect,” said Jason H. T. Karlawish, MD, associate professor of medicine and medical ethics at the University of Pennsylvania School of Medicine, and associate director of the Penn Memory Center. “Among the cluster of events in the terminal stage of Alzheimer disease are difficulties swallowing and a lack of drive to eat.”

At for-profit hospitals, he said: “There's a keen focus on length of stay and getting the patient back quickly to where he or she came from. In the case of a frail older adult with advanced dementia, coming from a nursing home with trouble swallowing, there would be pressure to say, ‘We have to get her eating, we'll put a feeding tube in so she can leave.’”

Although having frank conversations with families at such times can be difficult and time-consuming, neurologists should explain the importance of palliative care as an option, said James L. Bernat, MD, professor of neurology and medicine at Dartmouth Medical School, and former chair of the AAN Ethics Law & Humanities Committee. “There's a wealth of information to show that feeding tubes in this patient population are ineffective and even dangerous, yet they are still widely performed,” said Dr. Bernat, author of Ethical Issues in Neurology, 3rd ed. (Lippincott Williams & Wilkins, 2008). “Families need to be told that the appropriate care is palliative care. It's an active form of care, it's not nothing.”

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DR. JAMES L. BERNAT: “Theres a wealth of information to show that feeding tubes in this patient population are ineffective and even dangerous, yet they are still widely performed. Families need to be told that the appropriate care is palliative care. Its an active form of care, its not nothing.”

But a physician who researches the use of intensive services at the end of life said that a better focus of neurologists' educational efforts should be on hospital administration and staff.

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DR. AMBER E. BARNATO: “What Im emphasizing is that if theres something about hospital A vs. hospital B that causes me to end up with a feeding tube, neurologists should go into hospital A and hold the staff accountable.”

“I'm not arguing against educating families,” said Amber E. Barnato, MD, MPH, associate professor of medicine at the University of Pittsburgh School of Medicine and Graduate School of Public Health. “What I'm emphasizing is that if there's something about hospital A vs. hospital B that causes me to end up with a feeding tube, neurologists should go into hospital A and hold the staff accountable. They should say, ‘You are putting feeding tubes at disproportionate rates in my dementia patients. The evidence does not support the use of these for lengthening life or decreasing suffering in this patient group.’ Rather than talking to the patients and families, they should be talking to the hospital administrators and providers, to solve the problem at a system level.”

The powerful influence that a health care institution's priorities can have on such practices was described in a 2008 essay in JAMA, recounting how all the patients at a rural nursing home in the 1970s had feeding tubes, in part because the nursing staff had been frightened by their difficulty swallowing and had insisted on the feeding tubes as a solution.

“A lot of different factors get involved in patient-care decisions, not all of them involving the welfare of the patient,” said the essay author, Steven P. Ringel, MD, professor of neurology at the University of Colorado Health Sciences Center in Denver and editor in chief of Neurology Today.

A systematic literature review of feeding tubes for elderly dementia patients, conducted by the Cochrane Collaborative, concluded in April 2009: “Despite the very large number of patients receiving this intervention, there is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.”

The first author of the new JAMA study called on neurologists to familiarize themselves with the literature on the use of feeding tubes in advanced dementia.

“Neurologists have an important role in counseling the patient, if he or she is able to participate, and the family, regarding what decisions they're going to face in the future, and planting those seeds about making advanced-care planning,” said Joan M. Teno, MD, professor of community health at the Warren Albert School of Medicine, Brown University, and the Center for Gerontology and Health Care Research.

As an alternative to feeding-tube placement, Dr. Karlawish said, “My counsel to the family is that if you can, get in there and get by the bedside with a tray of food and a spoon, and give it your best shot to feed them. I myself would enjoy having someone sitting there patiently feeding me, as opposed to having someone rush in and hanging another bottle of enteral feeding solution.”

REFERENCES

• Teno JM, Mitchell SL, Gozalo PL, et al. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA 2010;303(6):544–550.
    • Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009;(2):CD007209.
      • Ringel SP. Lessons from the Santa Fe Trail. JAMA 2008;299(9):998–999.