Usage More Prevalent Among African-Americans
BY DANIEL GAITAN | firstname.lastname@example.org
Fewer nursing home residents with dementia are receiving feeding tubes, a result of increasing evidence that suggests the practice causes unnecessary suffering and does little to prolong life.
The proportion of advanced dementia patients who had feeding tubes placed when they were unable eat or drink on their own dropped 50 percent between 2000 to 2014 (12 to 6 percent), according to a new study published in the Journal of the American Medical Association.
Researchers with the Hebrew SeniorLife Institute for Aging Research, an affiliation of Harvard University, analyzed data from more than 71,000 nursing home residents across the U.S.
They also found that feeding tube use decreased across racial groups, but remained higher among blacks, declining from 38 to 18 percent. Among white residents, insertion rates declined from 9 to 3 percent.
“This decline parallels the emergence of research, expert opinion, and recommendations by national organizations discouraging this practice,” said lead author Dr. Susan L. Mitchell. No study in the past two decades has found that feeding tubes benefit these patients.
Researchers called for fiscal and regulatory policies to help discourage tube feeding and promote a more “palliative approach” to feeding problems among this population. Such an approach is intended to treat symptoms and side-effects of disease.
Mitchell, a clinical epidemiologist and geriatrician, spoke with Life Matters Media about her findings, feeding tube usage and end of life care.
Why do feeding tubes do little to prolong life among dementia patients?
Since 1997, there has been a body of research demonstrating the lack of benefit of feeding tubes in these patients in terms of prolonging life, preventing aspiration and preventing pressure ulcers.
The patients we talking about are in the final stage of dementia. They are so advanced in their disease and have such profound memory deficits that they don’t recognize their family members. They are bed-bound, dependent for all their functional activities, and they have minimal speech – often less than five words. These patients are in the very end, the terminal phase of their disease.
About 90 percent of these patients will have feeding problems – it is really part of the natural history of the terminal stage of this disease.
How do feeding tubes impact quality of life in a negative way?
We don’t know how uncomfortable people are, but I think the most important thing to consider, the main objective in delivering quality care for people with serious illnesses like this, is to provide treatments that are concordant with a patient’s preferences and wishes.
The main issue is providing informed decision-making that aligns with preferences. We know that when families really understand the eating problems and you ask what their goal of care is, most say their main goal is promoting comfort and using treatments that promote comfort versus life-prolongation. Over 90 percent will say that.
If you are talking about feeding problems and trying to align treatment choices with preferences, this really means a more palliative approach: only offering (food) to the extent that it is comfortable. Not tube feeding.
The first thing to think about when it comes to decision-making: what is the goal of care? If the goal of care is comfort, like it is for most people, tube feeding does not align.
If patients or families wish to know the risks and benefits of tube feeding and are in the small minority that wants to prolong life, we should explain to them that the evidence does not support prolonging life. Multi-step counseling has to happen.
Patients who opt for palliative care aren’t “stopping” treatments?
Palliative care medicine is about maximizing quality of life for patients with advanced illness. A palliative approach may be hand feeding – not trying to get in 2,000 calories for a patient a day– but providing food and mouth care to the extent that it is enjoyable.
You also found a racial divide when it comes to feeding tube use. Why are African-Americans more likely to receive feeding tubes?
It has been a very persistent finding across studies for a long, long time.
The observation extends not only to tube feeding but to other end of life outcomes as well – less use of hospice.
Blacks tend to experience more aggressive care at the end of life than whites. This is a disparity for which the underlying reasons are not well understood.
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