Saturday, November 12, 2016

Feeding Tube Trends in Elderly Alarm Experts

David S. Seres, MD, thinks too many nursing homes reject an inexpensive, nonsurgical procedure that can provide nourishment to patients who are temporarily too ill to feed themselves.

The procedure, a nasogastric feeding tube (NFT), is an old one—and one that has increasingly fallen out of favor in lieu of surgically implanted feeding tubes. Proponents of gastrostomies say they are safer even though they involve minor surgery, less prone to becoming clogged or yanked out, far more comfortable for patients and easier for caregivers to manage.

Dr. Seres, director of medical nutrition at Columbia University Medical Center, in New York City, conducted a survey that found only 18.3% of skilled nursing care facilities in New York City accept patients with NFTs, compared with 62% of nursing homes elsewhere in the United States (Nutr Clin Pract 2016;31:342-348). Dr. Seres said anecdotally, he has found a general East Coast bias among nursing homes that won’t admit patients with NFTs.

He noted that he is not opposed to percutaneous endoscopic gastrostomy (PEG), particularly if ill or elderly patients cannot feed themselves for extended periods. But, he said, many patients who are transferred to nursing homes are incapacitated for a month or less—recovering from a stroke, for instance—and will be able to feed orally sooner rather than later. In these cases, he said, nursing homes should accept patients with NFTs.

“It’s more of an ethical issue,” Dr. Seres said. “Without any medical justification, the nursing homes have determined that nasal feeding tubes are dangerous and scary. They’ve stopped using them and forgot how to. They are forcing patients to undergo a surgical procedure unnecessarily.” He likened the situation to the forced feeding that drew criticism when it was done to hunger-striking prisoners at Guantanamo Bay, in Cuba, only this time it’s on vulnerable patients who cannot be transferred from a hospital to a nursing home without a PEG.

As of 2010, some 6% of the 1.6 million Americans living in skilled nursing facilities were fed by a tube. Cognitive and physical impairments caused by stroke or dementia can make a person unable to swallow. Most patients with advanced dementia will be unable to feed themselves by mouth.

A gastroenterologist, using a scope and accompanied by anesthesia, will insert the PEG. Dr. Seres said these surgeries can cost upward of $1,000 compared with a NFT, which can cost $85 or less. Nurses and other workers are able to insert NFTs.

Nursing home executives in New York state say they rely on the recommendations of the hospital discharging the patient. They say they are also concerned that the NFT will not work, and the patient often ends up back in the hospital anyway.
“We don’t really see a lot of referrals,” said Nancy Leveille, RN, MS, senior director for member operational support for the New York State Health Facilities Association, in Albany. “There are times where they might have somebody in the hospital who has a nasogastric tube. Usually those are for short-term, temporary situations. The nursing home, if they were being referred somebody like that, would be evaluating: Is this going to be a long-term issue? This is going to be the main way of being fed? They may be talking to the hospital about a gastric tube so they don’t have to send them back for surgery later if surgical intervention is going to be needed in the long run.”

Timothy Lipman, MD, former chief of gastroenterology at the Department of Veterans Affairs Medical Center, in Washington, D.C., said the issue is complex. If the patient won’t need artificial feeding for more than two or three weeks, “I’d rather see the nasogastric tube,” Dr. Lipman said. “I think it’s reasonable if you know what you’re doing.” But he added that the tubes are uncomfortable, and tend to come out “not at 9 in the morning, but at night and on the weekend.”

‘Extremely Rare’

The Centers for Medicare & Medicaid Services (CMS) is agnostic on temporary feeding tubes. Its guidelines discourage the use of any tubes unless the resident’s condition makes them “unavoidable.” The agency also instructs nursing facilities using NFTs to “prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.”

CMS acknowledges that the use of NFTs has become “extremely rare” in nursing homes. “I have not seen a NFT on referral for years,” said Lisa Volk, RN, director of clinical and quality services for the New York State Health Facilities Association. There’s a reason, she said: “It’s constantly a source of irritation.” It also strips residents of their dignity, whereas a PEG can be underneath their clothing and out of harm’s way, she added.

An NFT is “not comfortable,” Dr. Volk said. “Your first impulse would be to get that out of there.” Complicating matters is that many nursing homes, unlike hospitals, do not use restraints to prevent residents from pulling out the tube. Patients who remove the tube risk returning to the hospital. “Fluid goes into the lungs and all of a sudden you have an aspiration problem,” she said.

Dr. Lipman, who is now retired, agreed that NFTs, which are narrower than PEGs, are more prone to clogging and displacement. “And the nursing homes think they don’t have the trained staff to put it back in, so they say, ‘We just don’t want to be bothered with these,’” he said. At the VA where he worked, one nurse was in charge of monitoring all gastrostomy tubes. Nursing homes lack people with experience in dealing with temporary NFTs because they don’t accept residents with them. “It becomes a self-fulfilling prophecy,” he said.

Dr. Seres said NFTs can become clogged, but putting them back in place should be easy. For him, doing so is far better than performing “unnecessary surgery in the sickest of patients in the hospital.” Dr. Seres also said some patients prefer an NFT to risking life-threatening complications from surgery, such as infection.  (Click to Continue)

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Feeding Tube Trends in Elderly Alarm Experts


Betty said...

In general, people don't understand feeding tubes. Nursing homes use them for convenience and that gives feeding tubes a bad rap.

Wendell Smith said...

Patient want it out even requested it .