Financial factors play part in nursing homes’ use of feeding tubes

by Scott J. Turner

Money may be at the root of the common practice of inserting feeding tubes into nursing home residents with end-stage dementia, even though the treatment neither delays death nor improve quality of life in the patients.

That was one of several chilling findings of a study published in the July 2 issue of the Journal of the American Medical Association (JAMA). Four of the five authors of the study are based in Brown’s Center for Gerontology and Health Care Research.

Harvard and Brown researchers analyzed 1999 records of 186, 835 patients with advanced dementia living in more than 15,000 U.S. nursing homes. More than a third of those residents had feeding tubes, with substantial variability in the practice nationwide and even within states.

The researchers associated several nursing home traits with higher use of feeding tubes in patients with severe dementia. These included for-profit status, fewer residents with do-not-resuscitate orders, lack of a special care unit for dementia, no nurse practitioner or physician assistant on staff, higher proportion of non-white residents, and urban location.

“A potential financial incentive exists for nursing homes to tube-feed patients,” said lead author Susan Mitchell, M.D., a researcher in the Research and Training Institute of Hebrew Rehabilitation Center for Aged in Boston. It costs less in staff time to tube feed rather than hand feed a patient, yet in many states, nursing homes receive a higher reimbursement rate for a tube-fed patient, she said.

For the proper care of patients with end-stage dementia, “you should first consider the use of the labor-intensive task of hand feeding,” said Joan Teno, M.D., professor of community health and medicine and one of the study authors. “Our bottom line is to provide directions such that the use of feeding tubes are based on the informed preferences of nursing home residents or their families.”

Instead of health care driven by reimbursement, “we want incentives for medical decisions that reflect informed preferences that weights the quality versus quantity of life,” Teno said.

Last year in a study published in JAMA, Teno and colleagues first described a striking state variation in feeding-tube use in nursing home patients with severe dementia. Previous research has shown that feeding-tube use does not improve quality of life, prolong life or help with aspiration or pneumonia in those patients.

Patients at end-stage dementia are unable to make their own decisions. This responsibility often falls on their family members who must make choices on patients’ behalf, which can be very complicated and emotional.

“The problem is largely an educational one,” Mitchell said. “End-of-life decision-making is very difficult, especially when people are not adequately informed or supported. Good decisions depend highly on the quality of counseling by health care providers.”

Do-not-resuscitate orders only reflect a choice not to be resuscitated in the event of a cardiac or pulmonary arrest, but do not directly translate into requests to withhold tube-feeding.

“It is likely that facilities with higher rates of do-not-resuscitate orders are better at engaging families in broader discussions about treatment preferences at the end of life,” Mitchell said.

Indeed, fewer feeding tubes are used in nursing homes “where there is a culture of discussion and more writing of do-not-resuscitate orders,” suggesting a greater degree of physicians willing to discuss end-of-life care, Teno said. “It suggests that those facilities more likely make decisions based on communication between physicians and patients and families. It comes down to better communications.”

Despite the fact that dementia is a terminal condition, it is often not perceived as such, said Mitchell. Whether to focus on comfort or to attempt tube feeding is one of the major dilemmas facing families, physicians and health care systems caring for these patients. “Nursing homes are increasingly the site of death for patients with advanced dementia and play a critical role in their end-of-life care,” she said.

The study findings are a chance for nursing home administrators and policymakers to examine how changes at the facility level can influence the “questionable practice” of tube feeding patients with advanced dementia, Mitchell said.

Senior author of the study is Vincent Mor, professor and chair of the Department of Community Health. The other Brown authors are undergraduate Glen Kabumoto and Jason Roy, assistant professor of community health.