Study into use of feeding tubes – surveying families

Though the two studies mentioned in this post refer to feeding tubes in those with dementia, many issues raised in this email are relevant to those without dementia as well.

Dr. Joan Teno, a community health physician and researcher at Brown University and Dr. Susan Mitchell, of the Hebrew Senior Life Institute for Aging Research, have researched feeding tube decisions over the last several years. Previously they found that “some American hospitals inserted no feeding tubes ­ zero ­ in patients with advanced dementia over an eight-year period while others [inserted feeding tubes in] one in three.” In their 2010 study, they concluded: “Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.”

Wanting to explore the discrepancy in feeding tube placements, these two researchers and a team surveyed family member, after their relatives’ deaths, on decisions they had made regarding feeding tubes. All of the deceased relatives had dementia. The researchers talked to nearly 500 people from five states — MA and MN, where there are low rates of feeding tube use, and AL, FL, and TX, where there are high rates of feeding tube use.

About 10% of the deceased relatives received a feeding tube. The New York Times reports that:

* “Of patients who received feeding tubes, 13.7 percent of family members reported that doctors had inserted the tubes without seeking permission at all.”

* “But even when medical providers raised the issue and a feeding tube was inserted, 12.6 percent of the family respondents said they had felt pressured by the physician to agree to the procedure, and more than half believed that the physician strongly had favored tube insertion.”

* “Moreover, these talks tended to be cursory: More than 40 percent of respondents said the discussion had lasted less than 15 minutes, and roughly a third said no one had mentioned the risks involved.”

* “In the end, about a third of these families said they thought the feeding tube did improve their loved ones’ quality of life, while only 23.4 percent said they regretted the use of the tube.”

Dr. Teno addresses why there’s a push for feeding tubes: “My guess is, we’ve changed hospital medicine to focus on discharge. How do we move someone quickly out of the system? You put the feeding tube in, you send people back to the nursing home.”

Dr. Paula Span, who wrote the New York Times article on the study, believes that the push for feeding tubes results from doctors not wanting to talk about death with their patients.

Here’s a link to the NYT article (with some interesting reader comments posted): … -in-haste/

And I’ve copied the abstract of the recent article authored by Teno, Mitchell, et al, below as well as their 2010 article on the differences in hospitals’ rates of feeding tube placement.


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

Joan M. Teno MD, MS, Susan L. Mitchell MD, MPH, Sylvia K. Kuo PhD, Pedro L. Gozalo PhD, Ramona L. Rhodes MD, MPH, Julie C. Lima PhD, MPH, Vincent Mor PhD

Journal of the American Geriatrics Society, 59. Article first published online: 3 MAY 2011

OBJECTIVES: To examine family member’s perceptions of decision-making and outcomes of feeding tubes.

DESIGN: 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.

SETTING: Nursing homes, hospitals, and assisted living facilities.

PARTICIPANTS: Respondents whose relative had died from dementia in five states with varying feeding tube use.

MEASUREMENTS: Respondents were asked about discussions, decision-making, and outcomes related to their loved ones’ feeding problems.

RESULTS: 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.

CONCLUSION: Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

PubMed ID#: 21539524 (see for this abstract only)

Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment

Joan M. Teno, MD, MS; Susan L. Mitchell, MD, MPH; Pedro L. Gozalo, PhD; David Dosa, MD, MPH; Amy Hsu, BA; Orna Intrator, PhD; Vincent Mor, PhD
Author Affiliations: Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island (Drs Teno, Gozalo, Dosa, Intrator, and Mor and Ms Hsu); Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts (Dr Mitchell); and Providence Veterans Affairs Medical Center, Providence, Rhode Island (Drs Dosa and Intrator).

JAMA (Journal of the American Medical Association). 2010;303(6):544-550.

Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization.

To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment.

Design, Setting, and Patients
The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital’s care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered.

Main Outcome Measure
Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization.

In 2797 acute care hospitals with 280 869 admissions among 163 022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement.

Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.

PubMed ID#: 20145231 (see for this abstract as well as a link to the full article at no charge)