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SUMMARY
FOR POLICY MAKERS
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"Terminal
dehydration" and the analgesic effect it brings about
appear to be a natural part of the dying process of many
diseases."
-
S.G. Post.
"Tube Feeding and Advanced Progressive Dementia".
Hastings Center Report 31, No. 1 (2001) 36-42.
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Policy
Concerns: Tube Feeding in Elderly Demented Patients
The US Supreme
Court has affirmed an individual right to forgo or withdrawal
life sustaining treatment, even including artificial nutrition
and hydration. Decisions about utilizing or stopping of feeding
tube should be made based on the informed preferences of a person
or a surrogate within the boundaries of state law. Existing synthesis
of the research literature has found that the use of feeding tubes
in patients with severe dementia does not prolong survival, prevent
aspiration pneumonia, or improve patient functioning (see
references below). Existing research, including findings
from the Brown Center for Gerontology and Health Care Research
has found dramatic variation in the use
of feeding tubes across the nation. The reasons for this ten
fold variation in the use of feeding tubes is not clear. Potential
reasons include state differences in nursing home regulatory oversight
regarding citing nursing homes for weight loss and dehydration,
financial incentives to provide overly technological care, and
physician practices in writing DNR orders. Patient preferences
as noted in the MDS with an order to forgo artificial hydration
and nutrition does not explain the observed state differences
in the use of feeding tubes. Ensuring that variation in feeding
tube use reflect patient preferences is an important priority
for policy makers.
How
do Nursing Home Regulations Affect the Decision to Tube Feed?
Federal regulations
require nursing homes to ensure that their residents are provided
with adequate nutrition and hydration. The Federal statute governing
grants to states for Medicaid programs mandates that "a nursing
facility must provide…dietary services that assure that the
meals meet daily nutritional and special dietary needs of each
resident." This statute is implemented by regulatory provisions
(see box below). Quality indicators,
which the Center for Medicare and Medicaid Services will report
for each Medicare certified nursing home in Fall 2002, monitor
rate of weight loss. Such quality indicators while drawing an
important focus on weight loss, may have the unintended consequence
of resulting in more feeding tube insertions.
Since two
systematic review of the literature have questions the benefits
of feeding tubes, routine insertion of a feeding tube as a strategy
for complying with government regulation is not the most effective
way of handling the situation. Rather, nursing homes should have
the adequate staffing to allow hand feeding of residents as a
standard of care. Feeding tubes should not be utilized as means
of achieving cost savings. Rather, the decision to utilize a feeding
tube should be based on patient need, their informed preferences,
and consistent with existing state law.
Both Federal
and State nursing home inspection should insure that an appropriate
work up of difficulty swallowing and weight loss is undertaken
and that patient informed preferences are considered in the decision
to insert a feeding tube.
- Nutrition.
Based on a residents' comprehensive assessment, the facility
must ensure that a resident maintains acceptable parameters
of nutritional status, such as body weight and protein
levels, unless the resident's clinical condition demonstrates
that his is not possible.
- Hydration.
The facility must provide each resident with sufficient
fluid intake to maintain proper hydration and health.
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How Does Current Medicare Reimbursement Polices Affect the Use
of Feeding Tubes?
The
financial incentives for nursing homes is to provide overly technological
care, rather than medical care that takes the time and effort
to ensure that patient preferences are considered in the decision
to use a feeding tube. Simply stated, nursing homes are reimbursed
at higher rate for the use of feeding tubes. "Skilled care"
days (for which tube feeding is included) reimburses nursing homes
a significantly higher amount than "Custodial care"
days, which would include assisted oral. Hand feeding of nursing
home residents with swallowing problems is labor intensive. Multiple
studies document inadequate staffing secondary to inadequate nursing
home reimbursement. Potentially, this leads to more feeding tube
insertions.
What Role do Physician's Play in Guiding Family Decisions?
First, physicians
must recognize that the use of feeding tubes is generally ineffective
in prolonging life, preventing aspiration, and even providing
adequate nourishment in severely demented patients. Physicians
should guide patients and families through the decision making
process of whether to use a feeding tube. Such discussions must
include frank information on the risks and benefits of using feeding
tubes in patients with severe dementia. Physicians must be pro-active
in demanding that patient receive appropriate swallowing assessment
and adequate trials of hand feeding.
Feeding Tube Resources and Position Statements:
American
Dietetic Association
Alzheimers
Association
American
Medical Association
American
Society for Parenteral and Enteral Nutrition
Gastrostomy
Support
References:
- Gillick,
M. R. Rethinking the role of tube feeding in patients with advanced
dementia. N Engl J Med 342(3), 206-10. 2000.
- Finucane,
T. E., Christmas, C., and Travis, K. Tube feeding in patients
with advanced dementia: a review of the evidence. JAMA 282(14),
1365-70. 99.
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