Dementia is now a leading cause of death in the United States
A study was published this week in JAMA (Journal of the American Medical Association) regarding nursing home patients with advanced dementia and who have feeding tubes inserted. The results showed that the frequency of feeding tubes is greater in for-profit hospitals versus government or state owned hospitals.
"A higher rate of feeding tube insertions also was independently associated with for-profit ownership vs hospitals owned by state or local government…
White residents had the lowest likelihood of feeding tube insertion, while black residents experienced nearly a 2-fold increase in the likelihood of feeding tube insertion…
Written advance directives, do not resuscitate orders,and orders to forgo artificial hydration and nutrition were independently associated with lower likelihood of feeding tube insertion."
Previous studies have found that the survival rate of patients with advanced dementia who have feeding tubes are not improved. It is estimated that one-third of nursing home residents with advanced cognitive impairment have feeding tubes inserted and the majority of these tubes are placed during acute care hospitalizations. Thereafter, many chronically ill patients continue to be maintained on tube feeding in ICUs in the last six months of life.
The use of advance health directives decrease the rate of patients on feeding tubes. Yet, as dementia advances it becomes increasingly difficult to obtain advance orders from patients who have lost the capacity to make decisions for themselves. It is estimated that the prevalence of dementia is 6% to 10% of people over 65, and thereafter continues to increase with age. The number of people aged 65 years and older is expected to increase from 35 million in 2000 to 71 million in 2030. The number of people aged 80 years and older is also expected to more than double,from 9.3 million in 2000 to 19.5 million in 2030.http://www.cdc.gov/pcd/issues/2006/apr/05_0167.htm
Failure to obtain advance health directives grievously impacts the lives of these patients and caregivers as well.
Early detection of dementia and early intervention to fully inform and ascertain the wishes of patients are therefore of great importance. Such efforts must be translated into public policy.
A face to face meeting between physician and patient or surrogate, clearly noted in the record, establishing an actual informed consent is the most reliable. This honors the patient’s dignity, and also protects physicians and hospitals from claims of wrongful death or physicians assisted suicide.
Further comments by the authors of the study published in the JAMA study are available, at http://www.eurekalert.org/pub_releases/2010-02/bu-sec020810.php