Would You Do This to Your Mother?

Abstract & Commentary

By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Directory, Sleep Disorders Center, Samaritan Hospital, Lexington, KY. Dr. Phillips is a consultant to Cephalon and serves on the speakers bureaus of Resmed and Respironics.

Synopsis: For-profit ownership, larger hospital size, and greater ICU use in the last 6 months of life was associated with increased rates of feeding tube insertion in nursing home residents with dementia who were admitted to acute care hospitals.

Source: Teno JM, et al. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA 2010;303:544-550.

The authors of this paper set out to identify the characteristics of hospitals that had high rates of endoscopic feeding tube insertion in nursing home residents with dementia who were admitted for acute care. They were interested in this issue because, although tube-feeding is of questionable benefit for nursing home residents with advanced dementia,1,2 a majority of U.S. nursing home residents who are tube-fed had their feeding tube inserted during an acute care hospitalization. The study population was selected from previously non-tube-fed nursing home residents with advanced cognitive impairment (ACI), age ≥ 66 years, who were hospitalized between 2000 and 2007. The authors chose a random 20% of such individuals from U.S. Nursing Home Minimum Data Set, which includes data on every resident living in all Medicare- or Medicaid-certified U.S. facilities. ACI was defined as a score ≥ 4 on the Cognitive Performance Score. The initial placement of a feeding tube was determined by examining Medicare claims data. The authors found 280,869 admissions among 163,022 nursing home residents over the study period (mean age, 84.0 years; 66.6% women; and 12.5% black). A total of 19,847 feeding tube insertions occurred in this group, of which 94.7% were percutaneous endoscopic gastrostomy feeding tubes. During the study period, the rate of feeding tube insertion decreased from 7.9/100 hospitalizations in 2000 to a low of 6.2/100 hospitalizations in 2007. Among the hospitals studied, the mean number of beds was 235, 18.5% were for-profit, and 30.8% had a medical school affiliation. The rate of feeding tube insertion varied from 0 to 39/100 hospitalizations. Higher rates of feeding tube insertion in demented nursing home residents were observed in hospitals that were for-profit (adjusted odds ratio [AOR], 1.33), had > 310 beds (AOR, 1.48), and had greater ICU use in the last 6 months of life (AOR, 2.60). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were not strongly associated with feeding tube placement.

Twelve percent of the hospitals did not insert any feeding tubes in this population of patients. These hospitals tended to be smaller, were more likely to be located in rural regions, and were less likely to be affiliated with a medical school, although medical school affiliation was not strongly associated with use of feeding tubes in this population. Hospitals that did not insert feeding tubes in demented nursing home residents were also less likely to use ICU care in the last 6 months of life.

Several characteristics of the nursing home patients were also independently associated with feeding tube use in cognitively impaired nursing home residents. Black residents experienced nearly a 2-fold increase in the likelihood of feeding tube insertion compared with whites. Written advance directives, do not resuscitate orders, and orders to forgo artificial hydration and nutrition were independently associated with lower likelihood of feeding tube insertion.

Commentary

Feeding tube insertion is often an agonizing decision for family members of those who are institutionalized for ACI. More than one-third of nursing home residents with advanced dementia have a feeding tube inserted,3 despite the fact that two literature reviews conclude that the use of feeding tubes in such patients does not improve survival, prevent aspiration pneumonia, heal or prevent decubitus ulcers, or improve other clinical outcomes.1,2 It turns out that a majority of these feeding tubes are placed during an acute care hospitalization, usually for an infection.4 Thus, a logical first step in reducing the burden of this futile care is to gain an understanding of the settings in which it is most likely to occur. The current study demonstrates that hospitals with higher rates of feeding tube insertion tend to be conspicuous consumers of health care; they are more likely to be larger in size, for-profit, and to expend more ICU days for decedents with chronic illnesses during the last 6 months of life. The lack of an association with feeding tube insertion in demented nursing home patients with teaching hospitals and with those with higher ratios of specialty care suggests that this increased use of resources does not necessarily result from increased patient acuity or from greater practitioner expertise.

The authors conclude that "Advance care planning is often lacking in nursing homes ... only 5.8% of hospitalized nursing home residents with advanced cognitive impairment had an order to forgo artificial hydration and nutrition despite the finding of O'Brien et al5 that most nursing home residents would 'rather die' than live in a state of advanced dementia with a feeding tube. Improving advance care planning is essential to ensure that feeding tube insertions are based on informed patient preferences."6,7

A full report of hospital rates of feeding tube insertions is available at www.LTCFocus.org.

References

1. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000;342:206-210.

2. Finucane TE, et al. Tube feeding in patients with advanced dementia. JAMA 1999;282:1365-1370.

3. Mitchell SL, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003;290:73-80.

4. Kuo S, et al. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc 2009;10:264-270.

5. O'Brien LA, et al. Tube feeding preferences among nursing home residents. J Gen Intern Med 1997;12:364-371.

6. Volandes AE, et al. Video decision support tool for advance care planning in dementia. BMJ 2009;338:b2159; doi: 10.1136/bmj.b2159.

7. Molloy DW, et al. Systematic implementation of an advance directive program in nursing homes. JAMA 2000;283:1437-1444.