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Do Patients With Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival?

Authors: Shubing Cai, Pedro L. Gozalo, Susan L. Mitchell, Sylvia Kuo, Julie P.W. Bynum, Vincent Mor, and Joan M. Teno

Journal of Pain and Symptom Management, 2012

Feeding tubes in dementia patients: No proven benefit

Loss of appetite is a common and distressing symptom patients experience with advanced dementia. A feeding tube is a medical device used to provide nutrition to those who cannot obtain nutrition by mouth, are unable to swallow safely or need nutritional supplementation. Feeding tubes are widely used in the treatment of dementia patients, but they have no proven benefit.

For example, feeding tubes have not been shown to improve survival, prevent aspiration or reduce the rate of pressure ulcers. Feeding tubes are usually placed when patients with dementia are admitted to the hospital. Different hospitals have a higher or lower tendency to place feeding tubes in patients with advanced dementia (range from 0% to 39%). Feeding tube placement may indicate more aggressive treatment practices. Thus, does being admitted to a hospital with a higher rate of feeding tube insertion correspond to an improved survival?

Records from 56,824 nursing home residents with advanced dementia admitted to 1,773 hospitals were evaluated for survival. Hospitals were grouped into three categories: high, medium or low feeding tube insertion rate. Those hospitals with a low feeding tube insertion rate had a high rate of completed advance directives (DNR or feeding restrictions). Among the nursing home residents, almost 30% died within one month of hospital admission and more than half died within six months. On statistical analysis, there was no difference in survival for patients admitted to hospitals with high or low feeding tube insertion rates.

This study raises many issues. Those hospitals with a high rate of feeding tube insertion, a marker for aggressive therapy, did not provide a longer survival for their patients with advanced dementia. Furthermore, the variation in rate of feeding tube placement among hospitals highlights the lack of objective guidelines available to aid in decision making for patients with advanced dementia.

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