Ramona L. Rhodes

Natural history of feeding-tube use in nursing home residents with advanced dementia.

OBJECTIVES Despite the evidence that feeding-tube use in persons with advanced dementia is not associated with improved outcomes, there remains striking variation in their use. Yet, little is known about the national incidence of feeding-tube insertions, the circumstances of their insertion, and post-insertion health care use. DESIGN Secondary analysis of Minimum Data Set merged onto Medicare Claims Files. SETTING AND PARTICIPANTS Nursing home residents (NHR) without a feeding tube. MEASUREMENTS NHR were followed for up to 1 year to see whether a feeding tube was inserted and then followed for 1 year after insertion to examine health care use and survival. RESULTS The incidence of feeding-tube insertion was 53.6/1000 residents. Most (68.1%) feeding-tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within 1 year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over 1 year, tube feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission. CONCLUSION Most feeding tubes are inserted in an acute care hospital. Feeding-tube insertions are also associated with poor survival and significant rate of health care use after insertion.

Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia.

Feeding and eating difficulties leading to weight loss are common in the advanced stages of dementia. When such problems arise, family members are often faced with making a decision regarding the placement of a percutaneous endoscopic gastrostomy tube. The existing evidence based on observational studies suggests that feeding tubes do not improve survival or reduce the risk of aspiration, yet the use of feeding tubes is prevalent in patients with dementia, and the majority of nursing home residents do not have orders documenting their wishes about the use of artificial hydration and nutrition. One reason is that orders to forgo artificial hydration and nutrition get wrongly interpreted as “do not feed,” resulting in a reluctance of families to agree to them. Furthermore, nursing homes fear regulatory scrutiny of weight loss and wrongly believe that the use of feeding tubes signifies that everything possible is being done. These challenges might be overcome with the creation of clear language that stresses the patients goals of care. A new order, “comfort feeding only,” that states what steps are to be taken to ensure the patients comfort through an individualized feeding care plan, is proposed. Comfort feeding only through careful hand feeding, if possible, offers a clear goal‐oriented alternative to tube feeding and eliminates the apparent care–no care dichotomy imposed by current orders to forgo artificial hydration and nutrition.

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

OBJECTIVES: To examine family members perceptions of decision‐making and outcomes of feeding tubes.

Does Feeding Tube Insertion and Its Timing Improve Survival

To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival.

Churning: The association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment

BACKGROUND There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment. METHODS A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment. RESULTS Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9-3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile. CONCLUSIONS Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.

What's race got to do with it?

If community foundations want to serve as leaders for their changing communities, understanding, reflecting, and contributing to emerging communities of color is no longer optional: it is essential. This is true across the board, not simply in areas undergoing intense demographic shifts. Community foundations are rooted in place, but they are also now inescapably connected to and affected by larger global trends and forces. Even the most isolated and homogenous of communities are no longer insulated from the dynamic pressures around them. As community foundations seek to adapt to these changes, showing leadership in meeting the challenges and opportunities presented by racial and ethnic diversity will be fundamental to their future success.

Multicenter External Validation of the Geriatric Trauma Outcome Score: A Study by the Prognostic Assessment of Life and Limitations After Trauma in the Elderly [PALLIATE] Consortium

BACKGROUND A prognostic tool for geriatric mortality after injury called the Geriatric Trauma Outcome Score (GTOS), where GTOS = [age] + [ISS × 2.5] + [22 if transfused any PRBCs by 24 hours after admission], was previously developed based on 13 years of data from geriatric trauma patients admitted to Parkland Hospital. We sought to validate this model. METHODS Four Level I centers identified subjects who are 65 years or older for the period of the original study. The GTOS model was first specified using the formula [GTOS = age + (ISS × 2.5) + 22 (if given PRBC by 24 hours)] developed from the Parkland sample and then used as the sole predictor in a logistic mixed model estimating probability of mortality in the validation sample, accounting for site as a random effect. We estimated the misclassification (error) rate, Brier score, Tjur R2, and the area under the curve in evaluating the predictive performance of the GTOS model. RESULTS The original Parkland sample (n = 3,841) had a mean (SD) age of 76.6 (8.1) years, mean (SD) ISS of 12.4 (9.9), mortality of 10.8%, and 11.9% receiving PRBCs at 24 hours. The validation sample (n = 18,282) had a mean (SD) age of 77.0 (8.1) years, mean (SD) ISS of 12.3 (10.6), mortality of 11.0%, and 14.1% receiving PRBCs at 24 hours. Fitting the GTOS model to the validation sample revealed that the parameter estimates from the validation sample were similar to those of fitting it to the Parkland sample with highly overlapping 95% confidence limits. The misclassification (error) rate for the GTOS logistic model applied to the validation sample was 9.97%, similar to that of the Parkland sample (9.79%). Brier score, Tjur R2, and the area under the curve for the GTOS logistic model when applied to the validation sample were 0.07, 0.25, and 0.86, respectively, compared with 0.08, 0.20, and 0.82, respectively, for the Parkland sample. CONCLUSION With the use of the data available at 24 hours after injury, the GTOS accurately predicts in-hospital mortality for the injured elderly. LEVEL OF EVIDENCE Prognostic study, level III.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma.

BACKGROUND When counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based. OBJECTIVE We sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities. METHODS Two cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects. RESULTS A total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60. CONCLUSIONS ISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

Barriers to End-of-Life Care for African Americans From the Providers’ Perspective Opportunity for Intervention Development

Research has shown that African Americans (AAs) are less likely to complete advance directives and enroll in hospice. We examined barriers to use of these end-of-life (EOL) care options by conducting semi-structured interviews with hospice and palliative medicine providers and leaders of a national health care organization. Barriers identified included: lack of knowledge about prognosis, desires for aggressive treatment, family members resistance to accepting hospice, and lack of insurance. Providers believed that acceptance of EOL care options among AAs could be improved by increasing cultural sensitivity though education and training initiatives, and increasing staff diversity. Respondents did not have programs currently in place to increase awareness of EOL care options for underrepresented minorities, but felt that there was a need to develop these types of programs. These data can be used in future research endeavors to create interventions designed to increase awareness of EOL care options for AAs and other underrepresented minorities.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents.

Background: Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions. Objective: The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time. Methods: In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006. Results: Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient’s best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often. Conclusions: Modest improvements were made over time in trainees’ exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists.