Focus On: Tube Feeding

March 25, 2010

Berman bioethicists question the benefits of tube feeding

For nursing home residents with advanced dementia, discussing the procedure “upstream” could lead to more rational decision-making when time comes


The nursing home just called to say that your mother is being rushed to the hospital because a severe infection. It soon becomes clear to the medical team that she is also malnourished. And just as you find her in the emergency ward, some doctor rushes in to get permission to insert a feeding tube.


Mom, in the advanced stages of dementia, is lying there, fragile and largely unaware. What do you say?


A new study published in the Journal of the American Medical Association has found that large and for-profit hospitals were more likely than others to give feeding tubes to just these types of elderly dementia patients.


The study begs questions about the merits of tube feeding elderly individuals with severe cognitive impairment. Families want assurance that doctors are doing all that they can for patients who are near death, which often means a feeding tube.

But a growing body of evidence raises serious concerns about the procedure’s benefits, high costs, risks of complications and discomforts.


 

“Beliefs about nutrition that are not supported by evidence are extremely abundant and often firmly held,” said Thomas Finucane, M.D., a Berman Institute faculty member who focuses on avoiding the overtreatment and under-treatment of the frail elderly. In studies he has authored, the evidence shows that tube feeding for patients with severe dementia does not prolong life, prevent suffering or improve function.


Beyond the headline


An estimated 1.5 million Americans age 65 and older live in nursing homes, according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. A recent study found that just over 5 percent of nursing home residents with advanced dementia were given feeding tubes, two-thirds of them inserted at an acute-care hospital.


Recent research found that more than two-thirds of persons with advanced cognitive impairment have their feeding tube inserted during an acute-care hospitalization—and usually for an infection.


Previous studies also have found that tube feeding is more common among African Americans and Hispanics than whites.


From the standpoint of the nursing home, there are financial incentives associated with feeding tube placement in residents with advanced dementia: They cost less relative to the amount of nursing time required for hand feeding. Furthermore, a tube-fed nursing home resident also results in a higher level of reimbursement from Medicaid. This was the conclusion of a 2003 study in the Journal of the American Medical Director’s Association.


“But from the perspective of Medicare, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications,” the authors stated.


Tube feeding the severely demented


In the context of runaway health-care costs, those advocating for reform and universal coverage say that a “rational, non-alarmist” discussion about rationing must begin now.


Meanwhile, critics of tube feeding say more must be done to make the public aware of the largely hollow promises of the procedure, its high cost and its health risks. At the Berman Institute, bioethicists point to what they think are better alternatives for feeding the severely demented when the simple act of eating becomes dangerous.


Finucane advocates a program of conscientious, careful hand feeding. “For severely demented patients, permanently recumbent with little muscle mass and little intake, actual nutrition requirements are very small,” he said. “In the days before feeding-tube mania, many such patients lived for two or three years on less than 1,000 calories per day.”



Eran Klein
, M.D., Ph.D., a Greenwall Fellow at the Berman Institute, suggests that nursing home operators consider having a discussion with families about feeding tubes early on, perhaps when they are admitting their loved one. The sit-down could be made standard by national nursing home associations, or even enforced as a prerequisite for Medicare payments, Klein said.


Before the program will pay for in-patient nursing home care, the operators will have to have checked off that the feeding-tube discussion with the resident’s family has taken place, said Klein, whose work focuses on normative issues in aging and cognitive impairment.


“That discussion needs to happen,” Klein said. “But it needs to happen far upstream from where it’s currently happening, which is either in the acute setting, which is not ideal, or in the nursing home setting, which is not ideal.”

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Contributors
Eran Klein
Michael Pena
Thomas Finucane

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