Decision-Making and Outcomes of Feeding Tube Insertion: A Five-State Study

Health Services, Policy, and Practice, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.57). 05/2011; 59(5):881-6. DOI: 10.1111/j.1532-5415.2011.03385.x
Source: PubMed


To examine family member's perceptions of decision-making and outcomes of feeding tubes.
Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life.
Nursing homes, hospitals, and assisted living facilities.
Respondents whose relative had died from dementia in five states with varying feeding tube use.
Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems.
Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not.
Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

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Available from: Vincent Mor, Apr 24, 2014
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    • "Thus, a Do Not Hospitalize (DNH) order is recommended for persons with advanced dementia (Mitchell et al., 2012; Volicer, 2005). The use of artificial nutrition and hydration is strongly discouraged in advanced dementia care (Teno et al., 2011). Recent recommendations continue to support oral feeding to the extent possible (Coyne & Lyckholm, 2010; Hospice and Palliative Nurses Association [HPNA], 2011; Kuo, Rhodes, Mitchell, Mor, &Teno, 2009; Mitchell et al., 2012). "
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    ABSTRACT: Family members of persons with advanced dementia may be asked to make complex treatment decisions without having adequate knowledge regarding the risks and benefits. This 6-month, prospective, randomized trial tested the effect of an intervention consisting of a face-to-face, structured conversation about end-of-life care options with family members of nursing home residents with advanced dementia. A comparison group received only social contact via telephone. Structured conversations between a palliative care team and intervention group family members included goals of care and how best to achieve those goals, and provision of psychosocial support. Psychosocial support was also provided via telephone at three 2-month intervals. Family members participated in three telephone interviews: baseline, 3, and 6 months. Specific advance directives for persons with dementia were extracted from medical records. Results showed that intervention families had higher satisfaction with care than comparison families at the 6-month time point, and they were more likely to have decided on medical options listed in residents' advance directives (Do Not Resuscitate, Intubate, Hospitalize) over time. Study findings reinforce the need for increased education and support for families around issues of end-of-life care decisions for advanced dementia.
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    • "It was reported that 26.1% of Canadian decision makers and 10.4% of US decision makers for tube feeding patients with dementia did not discuss feeding tube insertion [17]. A five-state study in the US showed that 13.7% of substitute decision makers did not discuss with the physician, and 12.6% felt pressured by the physician to insert a feeding tube [9]. In Japan, family members of elderly patients with advanced dementia decided on PEG based on their trust in the physician and their desire to prolong the patients’ life. "
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    ABSTRACT: In Japan, there is no decision-making guide regarding long-term tube feeding that specifically targets individuals making decisions on behalf of cognitively impaired older persons (substitute decision makers). The objective of this study was to describe the development and evaluation of such a decision aid. In this before-and-after study, participants comprised substitute decision makers for 13 cognitively impaired inpatients aged 65 years and older who were being considered for placement of a percutaneous endoscopic gastrostomy tube in acute care hospitals and mixed-care hospitals in Japan. Questionnaires were used to compare substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to a decision aid. The acceptability of the decision aid was also assessed. Paired t-tests were used to compare participants' knowledge and decisional conflict scores before and after using the decision aid. Substitute decision makers showed significantly increased knowledge (P < .001) and decreased decisional conflict (P < .01) regarding long-term tube feeding after using the decision aid. All substitute decision makers found the decision aid helpful and acceptable. The decision aid facilitated the decision-making process of substitute decision makers by decreasing decisional conflict and increasing knowledge.
    Full-text · Article · Feb 2014 · BMC Geriatrics
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    • "Another 59% reported no conversation with their health care provider regarding ways to manage eating and feeding. Moreover, 39% reported a physician bias toward feeding tubes, and 13% " felt pressured " to insert a tube (Teno et al., 2011). We propose an additional explanation for the continued use of feeding tubes. "

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