Abstract
Background
Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.
Methods
This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai‘i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.
Results
Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).
Conclusion
Using findings from our retrospective study of usual care, our NH’s interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.
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References
CMS. MDS Quality Measure/Indicator Report 2010; http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MDSPubQIandResRep/ qmreport.html. Accessed February 21, 2013.
Kimyagarov S, Turgeman D, Fleissig Y, Klid R, Kopel B, Adunsky A. Percutaneous endoscopic gastrostomy (PEG) tube feeding of nursing home residents is not associated with improved body composition parameters. J Nutr Health Aging. 2013;17:162–165.
Ribeiro Salomon AL, Carvalho Garbi Novaes MR. Outcomes of enteral nutrition for patients with advanced dementia: a systematic review. J Nutr Health Aging. 2015;19:169–177.
Watson N, Bell C. Cultural Considerations in Tube Feeding Decision-Making. SIG 14 Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations. 2014;21:63–73.
Robbins J, Butler SG, Daniels SK, Diez Gross R, Langmore S, Lazarus CL, Martin-Harris B, McCabe D, Musson N, Rosenbek J. Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. J Speech Lang Hear Res. 2008;51:S276–300.
Oldenbeuving AW, de Kort PL, Jansen BP, Algra A, Kappelle LJ, Roks G. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology. 2011;76:993–999.
Hanson LC, Carey TS, Caprio AJ, Lee TJ, Ersek M, Garrett J, Jackman A, Gilliam R, Wessell K, Mitchell SL. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc. 2011;59:2009–2016.
Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010;58:580–584.
Lopez RP, Amella EJ. Intensive individualized comfort care: making the case. J Gerontol Nurs. 2012;38:3–5.
Morris JN, Fries BE, Morris SA. Scaling ADLs within the MDS. J Gerontol A Biol Sci Med Sci. 1999;54:M546–553.
Morris JN, Fries BE, Mehr DR, Hawes C, Phillips C, Mor V, Lipsitz LA. MDS Cognitive Performance Scale. J Gerontol. 1994;49:M174–182.
Finestone HM, Woodbury MG, Foley NC, Teasell RW, Greene-Finestone LS. Tracking clinical improvement of swallowing disorders after stroke. J Stroke Cerebrovasc Dis. 2002;11:23–27.
Hurley AC, Volicer L. Alzheimer Disease: «It’s okay, Mama, if you want to go, it’s okay». JAMA. 2002;288:2324–2331.
Mitchell SL, Lawson FM. Decision-making for long-term tube-feeding in cognitively impaired elderly people. CMAJ. 1999;160:1705–1709.
Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ. 2004;329:491–494.
American geriatrics society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc. 2013;61:622–631.
Fischberg D, Bull J, Casarett D, Hanson LC, Klein SM, Rotella J, Smith T, Storey CP, Jr., Teno JM, Widera E. Five things physicians and patients should question in hospice and palliative medicine. J Pain Symptom Manage. 2013;45:595–605.
Vance J. AMDA-Choosing Wisely. J Am Med Dir Assoc. 2013;14:639–641.
Clarke G, Harrison K, Holland A, Kuhn I, Barclay S. How are Treatment Decisions Made about Artificial Nutrition for Individuals at Risk of Lacking Capacity? A Systematic Literature Review. PLoS One. 2013;8:e61475.
Snyder EA, Caprio AJ, Wessell K, Lin FC, Hanson LC. Impact of a decision aid on surrogate decision-makers’ perceptions of feeding options for patients with dementia. J Am Med Dir Assoc. 2013;14:114–118.
Gillick MR, Volandes AE. The standard of caring: why do we still use feeding tubes in patients with advanced dementia? J Am Med Dir Assoc. 2008;9:364–367.
Volandes AE, Barry MJ, Chang Y, Paasche-Orlow MK. Improving decision making at the end of life with video images. Med Decis Making. 2010;30:29–34.
Volandes AE, Mitchell SL, Gillick MR, Chang Y, Paasche-Orlow MK. Using video images to improve the accuracy of surrogate decision-making: a randomized controlled trial. J Am Med Dir Assoc. 2009;10:575–580.
Volandes AE, Paasche-Orlow MK, Barry MJ, Gillick MR, Minaker KL, Chang Y, Cook EF, Abbo ED, El-Jawahri A, Mitchell SL. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ. 2009;338:b2159.
Lopez RP, Amella EJ, Mitchell SL, Strumpf NE. Nurses’ perspectives on feeding decisions for nursing home residents with advanced dementia. J Clin Nurs. 2010;19:632–638.
Huang CS, Dutkowski K, Fuller A, Walton K. Evaluation of a pilot volunteer feeding assistance program: influences on the dietary intakes of elderly hospitalised patients and lessons learnt. J Nutr Health Aging. 2015;19:206–210.
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Bell, C.L., Lopez, R.P., Mahendra, N. et al. Person-centered feeding care: A protocol to re-introduce oral feeding for nursing home patients with tube feeding. J Nutr Health Aging 20, 621–627 (2016). https://doi.org/10.1007/s12603-016-0699-9
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DOI: https://doi.org/10.1007/s12603-016-0699-9