The Society for Acute Medicine, Spring Meeting, Radisson Blu Hotel, Dublin 3-4 May 2012

In-Patient Feeding Challenges

Dr Conal Cunningham, St. James’s Hospital,

Dublin

Feeding challenge

82 year lady with advanced dementia recovers from

pneumonia but eats very little

She repeatedly pulls out IV drips and NG tubes over the next

3 months

Medical team recommend a palliative approach but family

want a PEG tube

Family insist on repeated NG insertion and restrain their

mother with taped mittens and sit by her bed for long periods

holding her hands

This makes ward staff very uncomfortable

Gastroenterology team refuse to put PEG in as they feel its

unethical

You are asked for a second opinion

The Society for Acute Medicine, Spring Meeting, Radisson Blu Hotel, Dublin 3-4 May 2012

Tube feeding in Dementia

Ethics and Evidence

Malnutrition in Dementia

• Weight loss and malnutrition are common in dementia

• It may can occur at any stage of dementia (including before onset) – Very common in late disease

• Early stage dementia – Due to a mismatch between energy intake and expenditure

• Late stage dementia – Due to reduced intake

“Food refusal” in Dementia

• Patient doesn’t want to eat or doesn’t eat enough

– may eat if encouraged / assisted by others

• Can occur with dysphagia or on its own

• Can mask depression but usually due to a lack of hunger

and difficulty in feeding

• Occurs in mid to end stage dementia

Dysphagia in Dementia

• Patient unable to eat safely

• Increased risk of aspiration pneumonia and

choking

• End stage dementia

Supplemental feeding

• Sip feeding

• Hand feeding

• Tube feeding

• NG feeding

• PEG feeding

Hand feeding

• Survival of demented and non-demented in LTC is equivalent with a program of careful feeding by hand

• Franzoni S et al. J Am Geriatr Soc. 1996 Nov;44(11):1366-70.

• Hand feeding is much more expensive than tube feeding and remuneration is less

• Mitchell SL et al. J Am Med Dir Assoc. 2004 Mar-Apr;5(2 Suppl):S22-9.

Tube feeding

• PEG feeding much more effective than NG feeding at delivering calories

• NG tubes frequently blocked or dislodged and deliver only a fraction of the food delivered by PEG tube

– Park RH et al. BMJ. 1992 May 30;304(6839):1406-9.

• PEG feeding associated with a peri-procedural mortality of about 0-2%

– Hull MA et al. Lancet. 1993 Apr 3;341(8849):869-72.2.

– Kohli H, Bloch R. Am Surg. 1995 Mar;61(3):191-4.

Tube feeding in dementia

• A third of demented patients in US Nursing homes have feeding tubes

– Mitchell SL at al. Jama. 2003 Jul 2;290(1):73-80.

• Extensive regional variation (Maine 9% - Washington DC 64%)

• International variation in tube use by NH resident significant also – Ontario 15.0%

– Missouri 4.6%

– Iceland 1.3%

– Jensdottir AB et al. Int Nurs Rev. 2003 Jun;50(2):79-84.

Tube feeding in dementia

the evidence

• Does it prevent aspiration pneumonia?

• Does it prevent other infections?

• Does it prevent the consequences of malnutrition ?

• Does it improve survival?

• Does it prevent or improve pressure ulcers?

• Does it improve functional status?

• Does it improve patient comfort?

• Finucane TE at al. Tube feeding in patients with advanced dementia: a review of the evidence. Jama. 1999 Oct 13;282(14):1365-70.

Does tube feeding prevent aspiration

pneumonia? • No evidence that it does

• Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996 Nov 23;348(9039):1421-4.

• Post pyloric placement of feeding tube isn’t any better than gastric placement

• Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit

Care. 2003 Jun;7(3):R46-51.

• Tube feeding affects oesophageal sphincters and increases colonisation of upper GIT and may increase risk of pneumonia compared to hand feeding

• Feinberg MJ et al. Prandial aspiration and pneumonia in an elderly population followed

over 3 years. Dysphagia. 1996 Spring;11(2):104-9.

Tube feeding in dementia

• Does tube feeding prevent other infections? – No evidence / studies

• Does tube feeding prevent the consequences of malnutrition ? – No evidence

• Does tube feeding improve functional status? – No evidence

Tube feeding in dementia

• Does it improve patient comfort?

– Hunger and thirst rare in terminal patients

– McCann RM et al. Jama. 1994 Oct 26;272(16):1263-6.

• Does it prevent or improve pressure ulcers?

• No evidence that it does.

– In FOOD trial (stroke) PEG feeding increased risk of pressure sores vs NG

– Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.

Does tube feeding in dementia improve

survival?

• No randomised trials to date

• Many observational studies with very poor survival in PEG fed patients regardless of diagnosis – 25% mortality at 1 month and 50% at 6/12

– Mitchell SL, Tetroe JM. J Gerontol A Biol Sci Med Sci. 2000 Dec;55(12):M735-9.

– Rimon E et al. Age Ageing. 2005 Jul;34(4):353-7.

• Outcome in dementia probably worse – 50% mortality at 1 month and 75% at 6/12

– Sanders DS et al. Am J Gastroenterol. 2000 Jun;95(6):1472-5.

Risks of tube feeding

• Aspiration pneumonia (0-66%)

• Tube occlusion (2-35%)

• Local infection (4-16%)

Summary of risk benefits

• Tube feeding in dementia does not appear to prolong life, prevent infection, or relieve suffering for the patient

• Tube feeding in dementia is associated with operative and peri-operative risks to the patient

Why does tube feeding in dementia happen

then?

• Family factors

• Professional caregiver factors

• Institutional factors

Views of family and caregivers

• “No alternative”

– Think it may prolong life and relieve suffering

– Can’t let them “starve to death” – Callahan CM, Haag KM, Buchanan NN, Nisi R. Decision-making for percutaneous endoscopic

gastrostomy among older adults in a community setting. J Am Geriatr Soc. 1999

Sep;47(9):1105-9.

– Can’t let their relative die

Views of professional caregivers

– “No choice”

– 34% of medical and 44% of surgical consultants believed that feeding and hydration should always be continued even if other forms of treatment were stopped and patient was terminal

» Solomon MZ et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. 1993 Jan;83(1):14-23.

Institutional considerations

• PEG feeding is cheaper than hand feeding

• PEG feeding is less labour intensive

• PEG fed patients are easier (than hand fed) to discharge from hospital /place in a nursing home

• USA – Better renumeration from Medicare/Medicaid (USA) for PEG

fed patients

» Mitchell SL et al. Tube-feeding versus hand-feeding nursing home residents with

advanced dementia: a cost comparison. J Am Med Dir Assoc. 2004 Mar-Apr;5(2 Suppl):S22-9.

Which dementia patients get tube fed?

• Patient factors associated with tube feeding – Younger age,

– Non-white race,

– male sex,

– divorced marital status,

– lack of advance directives,

– a recent decline in functional status,

– and no diagnosis of Alzheimer disease.

• Nursing home factors associated with tube feeding – For profit NH

– located in an urban area

– having more than 100 beds

– and lacking a special dementia care unit

– a nurse practitioner or physician assistant on staff.

• Mitchell SL et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. Jama. 2003 Jul 2;290(1):73-80.

Ethical dilemma

• Patient benefits are very unclear

• Procedure has risks

• Patient’s ability to consent is reduced

• Main benefits are to others – (emotional / religious / financial)

Legal considerations

• Hand to mouth feeding is an ordinary intervention and cannot be withheld unless something else is put in place

• Tube feedings is an extra ordinary (or medical) treatment and can be withheld

• Ireland, UK, California

Conclusions

• Feeding issues occurring late in the dementing process are usually an indicator that the patient is entering a terminal phase and available evidence suggests that tube feeding does not prolong life or prevent suffering

• There is no evidence that tube feeding is any better than hand feeding though it is cheaper for the institution and associated with more risk to the patient

Conclusions

• Decisions should be

– made by the patient when competent

• ? role of advanced directives

– take into account the pre-existing wishes of the patient if available

– informed by the evidence

– Have input from the family if possible

– Independent of the wishes / beliefs of the treating staff

– Independent of financial considerations?

Bibliography 1

1.Cogen R, Weinryb J, Pomerantz C, Fenstemacher P. Complications of jejunostomy tube feeding in nursing facility patients. Am J

Gastroenterol. 1991 Nov;86(11):1610-3.

2.Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ, et al. Randomised comparison of percutaneous endoscopic gastrostomy and

nasogastric tube feeding in patients with persisting neurological dysphagia. Bmj. 1992 May 30;304(6839):1406-9.

3.Hull MA, Rawlings J, Murray FE, Field J, McIntyre AS, Mahida YR, et al. Audit of outcome of long-term enteral nutrition by percutaneous

endoscopic gastrostomy. Lancet. 1993 Apr 3;341(8849):869-72.

4.Hull MA, Rawlings J, Murray FE, Field J, McIntyre AS, Mahida YR, et al. Audit of outcome of long-term enteral nutrition by percutaneous

endoscopic gastrostomy. Lancet. 1993 Apr 3;341(8849):869-72.

5.Solomon MZ, O'Donnell L, Jennings B, Guilfoy V, Wolf SM, Nolan K, et al. Decisions near the end of life: professional views on life-sustaining

treatments. Am J Public Health. 1993 Jan;83(1):14-23.

6.Feinberg MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia. 1996

Spring;11(2):104-9.

7.Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996 Nov 23;348(9039):1421-4.

8.Franzoni S, Frisoni GB, Boffelli S, Rozzini R, Trabucchi M. Good nutritional oral intake is associated with equal survival in demented and

nondemented very old patients. J Am Geriatr Soc. 1996 Nov;44(11):1366-70.

9.Sartori S, Trevisani L, Tassinari D, Gilli G, Nielsen I, Maestri A, et al. Cost analysis of long-term feeding by percutaneous endoscopic

gastrostomy in cancer patients in an Italian health district. Support Care Cancer. 1996 Jan;4(1):21-6.

10.Bourdel-Marchasson I, Dumas F, Pinganaud G, Emeriau JP, Decamps A. Audit of percutaneous endoscopic gastrostomy in long-term enteral

feeding in a nursing home. Int J Qual Health Care. 1997 Aug;9(4):297-302.

Bibliography 2

11.Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med. 1997 Feb 10;157(3):327-32.

12.James A, Kapur K, Hawthorne AB. Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke. Age Ageing. 1998 Nov;27(6):671-6.

13.Callahan CM, Haag KM, Buchanan NN, Nisi R. Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 1999 Sep;47(9):1105-9.

14.Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. Jama. 1999 Oct 13;282(14):1365-70.

15.Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000 Jan 20;342(3):206-10.

16.Mitchell SL, Tetroe JM. Survival after percutaneous endoscopic gastrostomy placement in older persons. J Gerontol A Biol Sci Med Sci. 2000 Dec;55(12):M735-9.

17.Rudberg MA, Egleston BL, Grant MD, Brody JA. Effectiveness of feeding tubes in nursing home residents with swallowing disorders. JPEN J Parenter Enteral Nutr. 2000 Mar-Apr;24(2):97-102.

18.Sanders DS, Carter MJ, D'Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol. 2000 Jun;95(6):1472-5.

19.Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Arch Intern Med. 2001 Feb 26;161(4):594-9.

20.Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Arch Intern Med. 2001 Feb 26;161(4):594-9.

Bibliography 3

21.Tokuda Y, Koketsu H. High mortality in hospitalized elderly patients with feeding tube placement. Intern Med. 2002 Aug;41(8):613-6.

22.Jensdottir AB, Rantz M, Hjaltadottir I, Gudmundsdottir H, Rook M, Grando V. International comparison of quality indicators in United States, Icelandic and Canadian nursing facilities. Int Nurs Rev. 2003 Jun;50(2):79-84.

23.Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003 Jun;7(3):R46-51.

24.Mitchell SL, Teno JM, Roy J, Kabumoto G, Mor V. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. Jama. 2003 Jul 2;290(1):73-80.

25.Lang A, Bardan E, Chowers Y, Sakhnini E, Fidder HH, Bar-Meir S, et al. Risk factors for mortality in patients undergoing percutaneous endoscopic gastrostomy. Endoscopy. 2004 Jun;36(6):522-6.

26.Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. J Am Med Dir Assoc. 2004 Mar-Apr;5(2 Suppl):S22-9.

27.Rimon E, Kagansky N, Levy S. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups. Age Ageing. 2005 Jul;34(4):353-7.