Palliative care assessment rare before feeding-tube placement

Last Updated: 2016-12-13

By Anne Harding

NEW YORK (Reuters Health) - Patients rarely receive palliative care assessment before undergoing gastrostomy-tube placement, new findings suggest.

"Patients with serious illness have multiple nodal points in their trajectory of illness, and one of the problems I think in our medical system is that we let many of these nodal points slip by where we kind of roll along with usual care, ongoing aggressive interventions, without pausing to determine whether we are treating a patient based on the inertia of the medical system or a true knowledge of and interest in advancing patient-specific goals," Dr. Ana Berlin of Rutgers-New Jersey Medical School in Newark told Reuters Health.

"The decision to put a feeding tube in a patient is one of those nodal points. Despite the fact that it is, it's not really recognized or treated as such in prevailing medical practice," said Dr. Berlin, who worked on the study.

The findings were published online December 2 in Surgery.

Guidelines recommend palliative care assessment when considering a patient for gastrostomy-tube placement, Dr. Berlin and her team note in their report. The tubes may be placed for enteral feeding, or to treat obstruction with palliative decompression.

These patients are typically very ill with multiple, advanced comorbidities, the researchers note, and often may not have the capacity to decide whether to receive a feeding tube.

To investigate patient-centered outcomes and unmet palliative care needs in patients who receive gastrostomy tubes, the researchers looked retrospectively at 205 patients at their academic medical center.

Eight percent died in the hospital, while one-year mortality was 19%. Sixty-nine percent of the patients who survived to discharge were not able to live on their own. Patients with acute brain injury or respiratory failure fared worst, with 90% dying in the hospital or having severe disability at discharge.

Palliative care assessment before tube placement was documented in only 12% of patients.

At other centers, Dr. Berlin noted, the percentage of patients who receive a palliative care assessment before tube placement is likely lower. "We have a very unusual culture in our institution," she explained. "We have a strong palliative care presence and it's particularly strong in surgical specialties, which is different from most other institutions."

Feeding-tube placement usually is explained to patients and their surrogates in a very technical way that may not address quality-of-life issues, Dr. Berlin noted. And often, she pointed out, patients undergo gastrostomy placement so they can be discharged to long-term care facilities.

"If you have someone who has a devastating stroke and the question comes up of putting a feeding tube in them so they can go to rehab and it turns out the person would never have wanted to have been dependent on others to the degree anticipated . . . honestly a feeding tube is not going to get them toward where they want to be," the researcher said.

"If the same person tells you that as long as they can lay in bed and enjoy humor with their families and loved ones, and that's a life worth living, that's a very different person and decision-making scenario than the first patient," she added.

Dr. Berlin and her colleagues are now conducting a quality-improvement project with the goal of reducing the 88% gap in palliative care assessment at their center by half. Patients who undergo speech and language pathology evaluation for dysphagia now automatically undergo palliative care assessment.

SOURCE: http://bit.ly/2gvNUuR

Surgery 2016.