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Vol. LXIV, No. 13
June 22, 2012
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Harm Also Likely
Late-Life Care of Frail Elderly Is Often Capricious, Teno Says

On the front page...

One of the most fraught decisions in the medical care of elderly patients with advanced dementia is whether to insert a feeding tube or not. Those unfamiliar with the situation are apt to think, “Feeding is good. Go for it.”

But for experts like Dr. Joan Teno, professor of health services, policy and practice at Brown University’s Warren Alpert School of Medicine and a 20-year veteran of hospice care, that decision is not only often ambiguously reached, but also is demonstrably harmful to patients, resulting in earlier death and higher rates of infection, especially bed sores.

Speaking to the NIH end-of-life palliative care special interest group on May 17, Teno, an NIA grantee, presented data from recent studies showing how haphazard care is for this population nationally. In Los Angeles County alone, in hospitals only a mile apart, the feeding tube insertion rate varied from 3.3 per 100 to 13.2 per 100 in patients with similar diagnoses.

More disturbing, and obvious only to a physician experienced enough and compassionate enough to study such a disadvantaged, twilight population, FT insertion often has no benefit whatsoever, merely prolonging misery for the patient and his/her family. “The risk of tube insertion itself often outweighs potential benefits,” Teno said.

Continued...

This was one of those “if you only knew how risky it was, you’d think long and hard about ordering it” revelations that NIH audiences are sometimes privy to, and which, when more widely appreciated, may change medical practice nationally.

A major part of the problem is decision-making, Teno said. Because feeding often equates in the public mind with caring, the decision to withhold it, or to allow “comfort feeding” only, can seem inhumane. But few families and patients, and caregivers, devote much time or deliberation to the FT decision. When they do decide, emotion, habit, convenience or financial incentive tends to trump the evidence.

Dr. Joan Teno and her team examined factors associated with higher feeding tube insertion rates and found three main culprits: for-profit institutions, large hospitals and hospitals with more aggressive care.

Dr. Joan Teno and her team examined factors associated with higher feeding tube insertion rates and found three main culprits: for-profit institutions, large hospitals and hospitals with more aggressive care.

Meanwhile, Teno and her colleagues are producing a host of recent studies in major journals showing that FT insertion is often both useless and harmful.

The watershed study in the field was published in the Journal of the American Medical Association in 1999, led by Dr. Thomas Finucane. It was a qualitative synthesis of the literature that questioned the efficacy of feeding tube insertion. The tubes, in this study, were found not to be associated with: improved survival, healing of pressure sores, prevention of aspiration pneumonia or improved quality of life.

In an 18-month study of patients suffering from dementia in nursing homes in the Boston area, 86 percent were found to have eating problems and nearly 40 percent died within 6 months of developing the condition. Teno was second author on that paper, published in the New England Journal of Medicine.

In a nationwide study, using Medicare data, of more than 97,000 elderly nursing home residents with dementia, 64 percent died within a year of FT insertion. Sixty-eight percent of the FT insertions were performed during an acute-care hospital stay, meaning these patients were bouncing between nursing homes and hospitals.

Such “transitions,” Teno said, are not lightly borne by patients, who typically suffer relocation stress, increased risk of medical error, lack of coordinated care and special care needs that go unmet.

“Moving people in the last 90 days of life is not serving them,” she said. A variety of incentives, nonetheless, create a pathway of shuttling these patients off to the hospital rather than treating them in a nursing home. “It’s too easy for providers to simply send patients to the hospital,” Teno said.

Teno and her team examined factors associated with higher FT insertion rates and found three main culprits: for-profit institutions, large hospitals and hospitals with more aggressive care. “Follow the money—I think that’s a lot of what’s going on here,” she said.

In a 5-state survey of FT decision-making, researchers found that one-quarter of family members eventually regretted the decision. Half of respondents said the decision conversation lasted less than 15 minutes and, in half the cases, the attending physician strongly favored the procedure. Some 13 percent felt pressured by the doctor to agree to the procedure.

Over on the patient side, Teno showed, 39 percent of FT recipients were bothered by the procedure, 22 percent had to be restrained for FT insertion and 20 percent had to be “pharmacologically restrained.”

Just 3 days before the NIH lecture, Teno’s group published an article in the Archives of Internal Medicine concluding “the decision to insert a feeding tube in nursing home residents with advanced dementia is more about which hospitals you go to than a decision-making process that elicits and supports patient choice.” Further, “there are important risks to feeding tube insertions.”

The same paper also provides evidence of harm. “Those who got the tube tended to develop pressure ulcers,” Teno said. Diarrhea was also a common side effect and neuroleptics were often needed to calm unwilling recipients. “The body simply rejects [FT insertion],” she said.

“The patterns [in treatment of this patient population] we have right now don’t make sense,” Teno concluded. Her recommendations include fewer relocations of elderly patients with dementia, better decision support for both patients and families, more reliance on nurse practitioners and a “new order” of comfort feedings rather than tube insertion.

The goals of care should be paramount, she said. Hospitals, she argued, should be less about speed and more about quality. The result, Teno said, is likely to be improved survival, better care and cost savings. Win, win and win.


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