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Feeding Tubes In Nursing Homes: Benefit or Abuse

Posted Mar 07 2010 12:15pm
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By Jack Halpern

More than one-third of U.S. nursing home residents with advanced dementia have feeding tubes. About two-thirds of these have the tube inserted during an acute-care hospitalization.

Feeding tubes should only be used as a last resort because they lead to a loss of functioning, and can cause serious medical and psychological problems. If a resident is able to swallow and can get adequate nutrition by eating, no matter how long it takes, then no tube should be used. Lack of staff available to assist a resident with regular eating is not an acceptable excuse to install a feeding tube.

Larger hospitals and those that are set up to make a profit are more likely to use feeding tubes in patients with advanced dementia, despite evidence that the practice does not prolong life or help with bed sores and other problems.

Nursing home patients with advanced cognitive impairment often are fed through feeding tubes that were inserted during acute hospitalizations. To identify factors associated with feeding tube placement during acute hospitalizations, researchers analyzed Medicare claims files and federally mandated data collected from U.S. nursing homes. The study involved 163,000 nursing home patients with advanced cognitive impairment who were admitted to 2800 acute-care hospitals between 2000 and 2007.

According to a report published in The Journal of the American Medical Association, "About one third of U.S. nursing home residents with advanced cognitive impairment have feeding tubes. In this setting, such tubes can cause discomfort and have no demonstratable health benefits" (JAMA, July 2, 2009, pp. 73-80). The researchers found that residents were more likely to be given a feeding tube if they were younger, nonwhite, male, or divorced. Other risk factors included the absence of an advance directive, a recent decline in functional status, and the lack of an Alzheimer's diagnosis.

Data from several studies have failed to show significant improvements from tube feeding in patients with stroke or dementia, or in those who are critically ill.

The Feed or Ordinary Diet (FOOD) study included a subgroup of more than 800 stroke patients who were randomized to receive an immediate feeding tube or to wait a week before receiving a feeding tube (Lancet 2005;365:755-63). There were no significant differences in survival or functional recovery rates or in length of hospital stay between the two groups.

"The only significant difference was that more gastrointestinal bleeding occurred among patients who received feeding tubes immediately," Dr. Christmas said.

The use of feeding tubes was associated with reduced survival rates in a study of 2,000 critically ill patients (J. Am. Geriatr. Soc. 2000;48:S122-30). After controlling for severity of illness, enteral or parenteral feeding was associated with reduced survival among patients with adult respiratory distress syndrome and multiple organ system failure with sepsis, Dr. Christmas noted. Enteral feeding was also associated with worse survival rates in cirrhosis and chronic obstructive pulmonary disease.

Senile residents of nursing homes are more likely to be put on feeding tubes instead of being hand fed if they are black or Asian and live in a big urban nursing home run for profit, a new study finds.

The study, which surveyed 186,000 residents in all 15,135 licensed nursing homes in the country, sheds light on a debate among the operators of nursing homes and advocates for the aged over whether it is more humane or more sensible to put dying patients on feeding tubes.

The study appears today in The Journal of the American Medical Association. Its lead author, Dr. Susan L. Mitchell of the Research and Training Institute of Hebrew Rehabilitation for Aged in Boston, said the use of tubes was worrying ''amid growing empirical data and expert opinion indicating that feeding tube use has no demonstrable health benefits in this population and may be associated with increased risks and discomfort.

Most of these older patients are on Medicare and Medicaid, she explained, and the way that reimbursement works means nursing homes tend to ship them to hospitals when they get sick. Then, hospitals will try to discharge these patients back to the nursing home as quickly as possible. Inserting a feeding tube allows the hospital to discharge a patient faster, while for nursing homes, tube feeding is less time consuming than hand feeding.

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