People with advanced dementia who received a permanent feeding tube spent more time in the hospital, had more events and were more likely to have received a nasogastric tube even though they had discussions about care goals, consultations on palliative care and fewer comorbid conditions, a new study shows.
The report was published Monday in the Journal of the American Geriatrics Society.
The report explored the concept of “clinical momentum,” which describes the systems-level forces that lead up to intervention at the end of life.
Researchers used electronic health record data on hospitalized adults over 65 who had dementia, and who had an unplanned admission greater than three days between January 2015 and December 2022. The case group comprised 34 people who received a permanent feeding tube; they were matched with 34 controls who didn’t receive a feeding tube. Patients who already had tubes weren’t included. The average age of study participants was 80.2 years.
Feeding tubes were placed on day 15 after admission, on the median. One person in the case group and three in the control group died in the hospital. On average, patients in the case group experienced nine unique hospital events before feeding tube placement, while control patients experienced, on average, 4.9 events during their hospital stay.
In total, 52.9% of cases and 20.6% of controls had a “goals of care” meeting, while 29.4% of cases and 11.8% of controls received a palliative care consultation. Overall, 79.4% of people in the case group and 26.5% of controls received a bedside swallow consult, diet modification, nutrition consult, and swallow therapy; 73.5% of cases and 14.7% of controls also received a nasogastric/Dobhoff tube with this combination of treatment.
The authors pointed out a previous study showing that behavioral factors of clinical momentum can drive clinicians to prioritize a biomedical fix, which then starts a care trajectory that is difficult to disrupt.
Momentum can lead to additional tests and interventions that are difficult to withdraw once they are put into practice, the authors noted. For example, a healthcare professional may place a temporary nasogastric tube to address a problem, like aspiration, which then leads to a permanent tube if downstream forces — such as a nursing home’s requirement that patients to have a permanent tube — prevail.
