Thomas E. Finucane

Use of tube feeding to prevent aspiration pneumonia

In the US Medicare programme more than 75 000 percutaneous endoscopic gastrostomy tubes were placed during 1991, most of them in patients with head and neck cancer or neurogenic dysphagia due to dementia or stroke. For the neurogenic group, prevention of aspiration pneumonia is a common therapeutic goal. Yet tube feeding has not been shown to reduce the risk of aspiration or pneumonia. No randomised trials of the intervention have been done, and some data suggest ineffectiveness. Feeding tubes do not prevent aspiration of contaminated oral secretions or regurgitated gastric contents—both welldocumented causes of aspiration pneumonia. Although enteral feeding tubes are often placed to prevent aspiration pneumonia, they have long been cited as risk factors for aspiration pneumonia. 1 Here we review data on the incidence of aspiration pneumonia and mortality rates in patient receiving tube feeding, focusing on patients with neurogenic dysphagia. Methods

Predictors of nursing home placement in community-based long-term care

OBJECTIVE: To identify predictors for nursing home placement among a group of frail older patients receiving formal home care services.

Planning with elderly outpatients for contingencies of severe illness - A survey and clinical trial

The authors examined whether elderly patients would report positive or adverse emotional effects after their doctor, during a routine clinic visit, asked them to begin planning for future serious illness. Seventy-four patients, 65 years old or older, who were followed at a university hospital medical clinic were randomly allocated to an intervention or a control group. The intervention was a detailed discussion with the patient’s physician of the patient’s wishes about decision making and life support therapy in the event of extreme or incapacitating illness. A blinded interviewer then asked all consenting patients how they felt about the physician, the clinic visit, and their medical care. Intervention-group patients were questioned about their reactions to the physician and the discussion. Four important findings emerged: 1) Some emotional uncertainty was created when doctors raised these questions unexpectedly: one patient became visibly upset during the discussion, and three who gave consent to be interviewed afterward said that the discussion had made them wonder about their health. Nonetheless, all patients who received the intervention and completed the study were pleased that their doctor had asked. 2) Only 44% of all consenting patients reported having discussed these issues previously; only one had done so with a doctor. 3) 97% of patients who responded wanted to be kept informed by the doctor about their medical situations in times of serious illness. 4) Patients’ replies to specific questions about life-sustaining therapy in the event of their own severe illnesses were quite variable. During routine clinic visits doctors can encourage most elderly patients to begin specific planning for potential severe illnesses.

Malnutrition, Tube Feeding and Pressure Sores: Data Are Incomplete

PURPOSE: To review data about the relationship between pressure sores and (1) nutritional status, (2) nutrient intake, and (3) tube feeding.

The Outcome of CPR Initiated in Nursing Homes

To determine outcomes following attempted cardiopulmonary resuscitation initiated in nursing homes, we retrospectively reviewed ambulance and hospital records for all 705 people aged 65 or over who underwent attempted resuscitation by ambulance crews in 1987 in Baltimore City and Baltimore County. From medic unit encounter forms we noted whether or not the address of origin was a nursing home and to what hospital the person was taken. Hospital records were then examined to determine outcomes: death in the emergency room, death during consequent hospitalization, or live discharge. Complete information was obtained for all 117 nursing‐home residents and for 580 of 588 nonresidents. When attempted resuscitation was begun in a nursing home, only two patients survived to hospital discharge, whereas 61 nonresidents (11%) survived after a mean stay of 14 days. Of the 115 nursing‐home residents who did not survive to hospital discharge, 102 (89%) were pronounced dead in the emergency room, two (2%) more died within 24 hours of admission, and the remaining 11 (9%) died after an average stay of five days. Of the 519 nonresidents who died before discharge, 433 (83%) were pronounced dead in the emergency room, 16 (3%) died in the first 24 hours, and 70 (14%) lived an average of nine days. One of the two nursing‐home residents who survived was an 87‐year‐old woman who spent 30 days in the hospital and died eight months after returning to the nursing home, demented, cachectic, with a large sacral pressure sore. The other was an 81‐year‐old man who, after a 60‐day hospitalization, returned to the nursing home and died there 14 days later. We conclude that the benefits of cardiopulmonary resuscitation initiated in nursing homes are extremely limited.

Planning for death but not serious future illness: qualitative study of housebound elderly patients

Abstract Objective: To understand how elderly patients think about and approach future illness and the end of life. Design: Qualitative study conducted 1997–9. Setting: Physician housecall programme affiliated to US university. Participants: 20 chronically ill housebound patients aged over 75 years who could participate in an interview. Participants identified through purposive and random sampling. Main outcome measures: In-depth semistructured interviews lasting one to two hours. Results: Sixteen people said that they did not think about the future or did not in general plan for the future. Nineteen were particularly reluctant to think about, discuss, or plan for serious future illness. Instead they described a “one day at a time,” “what is to be will be” approach to life, preferring to “cross that bridge” when they got to it. Participants considered end of life matters to be in the hands of God, though 13 participants had made wills and 19 had funeral plans. Although some had completed advance directives, these were not well understood and were intended for use only when death was near and certain. Conclusions: The elderly people interviewed for this study were resistant to planning in advance for the hypothetical future, particularly for serious illness when death is possible but not certain.

Racial bias in presentation of cases

To investigate whether medical housestaff report race information differently during case presentations of black patients and white patients, a prospective observational study was performed. Without informing housestaff, a chief resident recorded data during consecutive case presentations over two months. For each presentation, the data included: 1) whether, where, and how often race was identified; 2) whether certain prospectively selected, “possibly unflattering characteristics” were mentioned; and 3) whether any “justifying” diagnoses were considered during presentation or subsequent discussion. Justifying diagnoses were those in which a patient’s race was important in considering the likelibood of possible diagnoses. Twenty-three bouse officers presented 18 black and 35 white patients. A single East Indian patient was excluded from analysis. Race was specified more often during presentations of black than of white patients (16 of 18 for blacks vs. 19 of 36 for whites; p<0.01). For two black patients, a justifying diagnosis was considered, but excluding these patients did not change the results. Two other differences did not achieve statistical significance. Race was more often specified prominently and repeatedly during presentations of black patients. Among patients to whom “possibly unflattering” characteristics were attributed, race was more likely to be specified for blacks (10 of 10) than for whites (4 of 9). These case presentations appeared to show a subtle bias.

American geriatrics society identifies another five things that healthcare providers and patients should question

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its “Choosing Wisely” campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things—tests, medications, or procedures—that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaigns website (www.choosingwisely.org). The first AGS list was published in February 2013.

Differences in end-of-life preferences between congestive heart failure and dementia in a medical house calls program

Objectives: To compare end‐of‐life preferences in elderly individuals with dementia and congestive heart failure (CHF).

A Tool to Strengthen the Older Patient–Companion Partnership in Primary Care: Results from a Pilot Study

To determine the acceptability of a pre‐consultation checklist for older adults who attend medical visits with an unpaid companion and to evaluate its effects on visit communication.