feeding tubes in paents with demen.a: providing clarity ... library/sgim/resource... · feeding...
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FeedingTubesinPa.entswithDemen.a:ProvidingClarityAmongsttheConfusion
KevinSmith,MD,FACP,FAPLoyolaUniversityMedicalCenter
AssociateChiefMedicalOfficerforQualityandSafetyAssistantProfessorofMedicineandPediatrics
UniversityofChicago
Disclosures
• Nosignificantfinancialrela.onshipstodisclose
Objec.ves• Reviewepidemiologyofdemen.aandea.ngissues
• Discussevidenceregardingtubefeedinginpersonswithadvanceddemen.a
• Describeevalua.onandmanagement,includingcommunica.onstrategies,whencaringforpa.entswithadvanceddemen.aandea.ngissues
CasePresenta.on• 87yearmalewithhypertensionandadvanceddemen.a(x
10years),bedbound,fullcarebyhisdaughter,includinghandfeeding
• BroughtinthroughERwithintermiXentrefusaltoeator
drink,inconsistentlyswallowingmedica.ons,pocke.ngfoodandfoundtohaveaspira.onpneumonia
• Onexamcachec.celderlymale,contracted,non-verbal,stage2sacralpressureulcer,coarserhonchirightlung
• Labs:WBC20K,Na=155,BUN/Cr(50/1.6),increasedfrom
baseline
CasePresenta.on• Ea.ngissuesemerged6monthsagowhenhewasresidinginanursing
facility
• Daughterfeltpressurefromfacilitytoplaceapercutaneousgastrictubeamidconcernsofweightloss
• Sheul.matelydecidedtore.refromworkandbecomeherfather’sfull-.mecaregiver
• Noknownadvancedirec.vesabouthiswishesrelatedtonutri.onatEOL
• Sheissecond-guessingherdecisiontoforgofeedingtube
• Pallia.vecareconsultedtoreviewgoalswithdaughter
Epidemiology
• Demen.aprevalenceUnitedStates:4.4million(2010)→11million(2050)
• U.S.(2010):5thleadingcauseofdeathage65andolder• Mediansurvival:onset=3-12yrs;diagnosis=3-7yrs• NHresidentsMitchellNEJM2009
-38%developea.ngissueslast6monthsoflife-1/3havefeedingtubes,10foldregionalvaria.on
InfluencesforTubePlacement• Localprac.cecultureandphysicianpreference
• Caregiverpreferenceandemo.ons
• Presenceorabsenceofadvancedirec.ves
• Legal,regulatoryissues
• Clinicalconcerns-malnutri.on,medica.ons,aspira.on,pressureulcers,starva.onanddeath,qualityoflife,comfort
SummaryoftheEvidence
• Cochranereview2009-Limiteddata:NoRCTs,6observa.onalstudies
• Noevidencethatenteralfeedingprolongssurvival,improvesqualityoflife,enhancesnutri.on,ordecreasestheriskofpressureulcersinpa.entswithadvanceddemen.a
BCandyInternJourPallNursing2009
SummaryoftheEvidence
• Prospec.vecohortstudy,1999-2007-36,000U.S.NHresidents-Propensitymatched:tubefedvsnotubefed• Neitherinser.onoftubenor.mingofinser.onaffected
survival(6months)JTenoJAmGeriatriSoc2012
• Tubefedpa.ents2.27.mesmorelikelydeveloppressureulcersand30%lesslikelytohealexis.ngulcers JTenoArchInternMed2012
SummaryoftheEvidence
• Nostudyhasshowndecreaseinriskofaspira.onpneumoniafromPEGplacement
• Doesn’tpreventaspira.onoforalsecre.ons
• Refluxedgastriccontentscans.llbeaspirated– Enteralfeedingmayincreaseriskofaspira.on(datamixed)– Loweresophagealpressureisdecreasedintubefedpa.ents– JejunostomytubesmaynotbebeXerthangastrostomytubes
Finucane TE. JAMA 1999; Dharmarajan TS. Am J Gastroenterology 2001
SummaryoftheEvidence
• StudiesofdyingcancerorALSpa.entswithanorexia:– LiXlehungerorthirst
• Anythirstcanbetreatedwithmouthswabsandicechips
– Senseofeuphoria(endorphins)• Goesawayiffed
– Pa.entswerelenalonemore
Gillick MR. NEJM, 2000; McCann RM, JAMA, 1994
FeedingTubesRisksandQOLIssues
• Periproceduralmortality6-28%
• Mortalityinyearanerplacement(64%),median56days
• Replacement/reposi.oning(20%),median145days
• Average9hospitalizeddays/pa.entyearanerplacement
• Increasesocialisola.onbyremovingcontactatmeal.me
• Increaseuseofphysicalandchemicalrestraints(30%)
SMerelClinGeriatrMed2014
TheCostofFeedingTubes
• Ini.alplacement$2200/person
• Complica.onsoneyearanerinser.on$2449/person
• Newfeedingtubesqualifyfor100daysofMedicareskillednursingbenefits
• MedicaidperdiemreimbursementhigherforpersonswithTF
($190vs.$151/day)
CallahanCMetal.JAmGeriatrSoc2001;MitchellSLJAmGeriatrSoc2003
PhysicianBarrierstoLimi.ngPEGPlacement
• Survey500primarycarephysicians
• AMAmasterfile
• Responserate47%
• 87%tookcareofdemen.apa.entsinpastyear
• 75%haddiscussedPEGissue
JShegaetal.JournPallMed2003
Physicians’Percep.onsonTubeFeeding
• Reducedaspira.onpneumonia 76%
• Improvedpressureulcerhealing 75%
• Improvedsurvival 61%
• Improvednutri.onalstatus 94%
• Demen.aisaterminaldiagnosis 78%
• PEGisstandardofcare 51%
• PEGshouldbestandardofcare 26%
FeedingTubeDiscussionswithProvider
• Caregiverfollow-backsurvey486familymembers• Ofthe10%withfeedingtubes:-13%hadnodiscussionaboutinser.on-41%haddiscussionlas.ng<15minutes-Risksnotdiscussedin1/3cases-52%feltclinicianstronglyfavoredinser.on
• LovedonesofthosewhodiedwithfeedingtubelesslikelytoreportexcellentEOLcare
JTenoJAmGeriatrSoc2011
WhenDemen.aPa.entIsnotEa.ng
Considerthis:Anorexiavs dysphagiavs agnosia/apraxiavs agita.on
• AcutevsChronic
– acute(thencantreatunderlyingcause?)– chronic(duetodemen.aitself?)
ReframingtheDiscussion:“ComfortFeedingOnly”
• Providesac.velanguage
• “Comfort”means:-Handfeedingaslongaspa.entnotshowingsignsofdistress(e.g.coughing,choking)-Leastinvasiveandmostsa.sfyingwaythataXemptsnutri.on-Ifhandfeedingstopped,con.nueengagingwithoralcare,reading/talking,therapeu.ctouch
• Goal:socialandphysicalcontactmorethannutri.onalhealth
PalecekJAmGeriatrSoc2010
Value-basedCommunica.onTips• Setuptheinterview
• Obtaincaregiver’spercep.onofillness-Obtainobserva.onalandemo.onaldata
• Giverelevantdata,bestavailableevidence
• Elicitconcerns,valuesandgoals
• Bemindfulofprognos.cuncertainty
• Makearecommenda.on
• Presentgoalsandplanforeachgoalbasedoncaregiver’svalues
• Balancerealismandhope
Revisi.ngourCase• 87yearmalewithadvanceddemen.a,bedbound,fullcare
byhisdaughter• IntermiXentrefusaltoeatordrink,inconsistently
swallowingmedica.ons,pocke.ngfoodandfoundtohaveaspira.onpneumonia
• Daughterfeltpressurefromfacilitytoplacefeedingtubeandisnowsecondguessingherdecision
• Noadvancedirec.vesinplace
Howwouldyoumanagethiscase?
Resources• Forcaregivers• hXps://decisionaid.ohri.ca/docs/das/Feeding_Op.ons.pdf• hXps://www.compassionandsupport.org/index.php/
for_pa.ents_families/life-sustaining_treatment/ar.ficial_hydra.on_and_nutri.on
• Forclinicians• hXp://www.compassionandsupport.org• ChoosingWisely–AAHPM,AGS• hXp://www.choosingwisely.org/pa.ent-resources/feeding-
tubes-for-people-with-alzheimers/
Hemodialysis(HD)intheElderly:IsItAlwaysAboutFixingthatNumber?
AzizAnsari,DO,SFHM,FACPAssociateDirector,DivisionofHospitalMedicine
MedicalDirector,LoyolaHomeHospiceAssociateProfessorofMedicine
Disclosures
• NosignificantfinancialrelaEonshipstodisclose
• IdonotplayacomedianonTV
ObjecBves
• IdenBfytheimpactofiniBaBngdialysisinpaBentswithESRDwithmulBpleco-morbidiBes
• ReviewtheeffectsonfuncEonalstatusaMerstarEngdialysisintheelderly
• DiscusschallengesregardingadvancecareplanninginpaEentswithESRD
Let’sBeginwithaCase• Youhavea81yearoldmalewithmoderatedemenEa,PVD,CAD,chronicsystolicheartfailurewithanEFof25%,diabetes,andStageVCKDwhomaybeonthevergeofstarEngdialysis
• HisdaughterisinsistentonstarEngHD,because“wehavetodoeverythingyoucandoctortosavehislife”
• HehasmulEpleADLimpairmentsincludingrequiringacanetoambulateandassistancewithdressingandbathing
• Whatdoyourecommend?
WhatistheoneyearmortalitywhenstarBngHDinpaBentsolderthan70yearsofage?
TheScopeoftheProblem
• Agegroup>75yearsarethefastestgrowinggroupofincidentESRDpaEents
• MortalityinthefirstyearaMerstarEngdialysisexceeds35%amongpaEentsolderthan70yearsofage– Exceeds50%amongpaEentsolderthan80yearsofage
TheScopeoftheProblem:AComparaBveSurvivalStudy
• AretrospecEveanalysisofthesurvivalof129paEents>75yearsofagestarEngHD
• TheDialysisgroup(n=52)hadaoneandtwoyearsurvivalof84%and76%respecEvely
• TheConservaEvegroup(n=77)hadaoneandtwoyearsurvivalof68%and47%respecEvely
• SothismeansthatHDsaveslivesinalltypesofpaEents,right?
Murtaghetal.2007
TrueorFalse:
Whenfacingco-morbidiBesintheelderly,HDsurvivaldifferencesarelessevidentcomparedtoconservaBvetherapy…
Kaplan–Meier survival curves for those with high comorbidity (score = 2), comparing dialysis and conservative groups (log rank statistic <0.001, df 1, P = 0.98).
Murtagh F E M et al. Nephrol. Dial. Transplant. 2007;22:1955-1962
© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: [email protected]
Comorbidityscoresof2especiallywhenincludingischemicheartdiseasedidnotshowasurvivaldifference
Time to death in “Frail patients”
Kirsten L. Johansen et al. JASN 2007;18:2960-2967
©2007 by American Society of Nephrology
WhatAboutConservaBveTreatment?
• SingleCenterstudyintheUKof202ESRDpaEents>70yearsofage– ConservaEvetherapy(MCM)à29paEents– RRTà173paEents
• Mediansurvival:– 37.8monthsintheRRTgroupvs.13.9monthsintheMCMgroup– MCMgrouphoweverhadlongersurvivalEmescomparedtoprevious
studies(rangingfrom2-46days)
• RRTgrouphadhigherratesofhospitalizaEons(25days/pt/yearvs.16days/pt/year)
• MCMgrouphadaOddsRaEoof4.15greaterlikelihoodofdyingathomeorinhospicecomparedtoRRTgroup
Carsonetal.CJASN2009
ARecentStudyonComparaBveSurvival
• Dutchstudywhere107paEentschoseconservaEvemanagement(CM)and204choseRRTwithsimilarco-morbidityscores
• SurvivaladvantageseenintheRRTgroup
• HoweveraMer80yearsofage,thesurvivaladvantagewasnolongerobserved(p=0.08)
• PaEentsover70yearsofagewithco-morbidiEes,especiallycardiovascularissues,haddecreasedsurvivaladvantages(thoughRRTgroupsEllhadastaEsEcallysignificantadvantageforsurvival)
Verberne,etal.CJASNMarch2016
UsingtheCharlsonCo-MorbidityIndex
• 268paEentsonHDobservedinonestudy
• ThehighertheCCI,thehigherriskofhospitaladmissionsandmortality(HR1.24)
• PaEentswithveryhighscores≥8have1yearmortalityof48%
Beddhuetal.AJM2000
TheScopeOfTheProblemBeyondSurvival
• Falls:– >45%ofelderlydialysispaEentshave≥1fallayear – MortalityinHDincreasedwithatleast1fall(HR1.63)
• CogniBveImpairment:– CogniEveimpairmentanddemenEatwicehigherinESRDpaEentsthaninthegeneralpopulaEon
– FasterratesofcogniEvedecline
• Pain:– Chronicpainin50-79%ofdialysispaEents(comparedtogeneralpopulaEonwithchronicpainaround2-45%)
BeregerJR,HedayaEss,CIASN2012WesibordetalJASN2005
ObjecBves
• IdenEfytheimpactofiniEaEngdialysisinpaEentswithESRDwithmulEpleco-morbidiEes
• ReviewtheeffectsonfuncBonalstatusaXerstarBngdialysisintheelderly
• DiscusschallengesregardingadvancecareplanninginpaEentswithESRD
WhathappenstoFuncBonalstatusaXeriniBaBngHDintheelderly?
IncreasesDecreases
StaystheSame
Characteristics of the Subjects at the Initiation of Dialysis
Kurella Tamura M et al. N Engl J Med 2009;361:1539-1547
• RetrospecEvestudylookedat3702NHresidentsstarEngHDbetweenJune1998andOctober2000
• AimwastostudytrajectoryoffuncEonalstatusbeforeandaMeriniEaEonofdialysisamongelderlyNHpaEents
Change in Functional Status after Initiation of Dialysis
• FuncEonalstatusmaintainedat12monthsinonly13%ofpaEents(1outof8paEents)
• CumulaEvedecreaseinfuncEonalstatusof29%atoneyear
• CumulaEvemortalityrateof59%at1year
• WorseADLscores3monthsaMeriniEaEonofHD
FuncBonalStatusDecline• IniEaEonofDialysis(periodencompassing3monthsbeforeand1monthaMerstarEngHD)wasassociatedwithadeclineinfuncEonalstatus
• CoexisEngmedicalcondiEonssuchasCVA,demenEa,hospitalizaEons,andlowalbuminlevelswereassociatedwithloweroddsofmaintainingpre-dialysisfuncEonalstatusat1year
• NodatatoshowthatfuncEonalstatusimprovedwithHD
SoWhydoPaBentsDeclineonHD?
• HighprevalenceofbaselinedisabilitysuchastendencyforfallsandcogniEvedysfuncEon
• CoexisEngcondiEons:– DemenEa– CVA– Diabetes
SoWhydoPaBentsDeclineonHD?
• PhysicalandpsychosocialrisksofHD– VascularaccessandlineinfecEons– LessEmeforphysicaltherapy– SymptomsfromHDsuchasdizzinessandlowbloodpressure
• IskidneyfailureaconsequenceofterminalmulEorgandysfuncEon?– IsHDgoingtosolvetheunderlyingproblem?– IsthedisabilityaconsequenceofclinicaleventsmorerelatedtocoexisEngcondiEons?
WhathappenstoFuncBonalStatusforthosepaBentswhodoNOTstartHD?
ItdeclinesasquicklyasthosewhostartHD
ItdeclinesbutNOTasquicklyasthosewho
startHD
WhataboutFuncBonalStatusandNOTstarBngHD?
• Longitudinalcohortstudyof75paEentsintheUKlookingatfuncEonalstatusinpaEentsopEngforconservaEvemanagement
• 66%diedduringfollowup
• FuncEonalstatusremainedstableduringthelastyearoflifebutdeclinedsteeplyinthelastmonthoflife(comparedtothepreviousstudywhichshowedadeclineinfuncEonalstatuswhenstarEngHD)
Murtaghetal.JAGS2011
ObjecBves
• IdenEfytheimpactofiniEaEngdialysisinpaEentswithESRDwithmulEpleco-morbidiEes
• ReviewtheeffectsonfuncEonalstatusaMerstarEngdialysisintheelderly
• DiscusschallengesregardingadvancecareplanninginpaBentswithESRD
SummaryofSharedDecisionMakingGuidelines
• SharedDecisionMaking– InvolvethepaEent
• InformedConsentorRefusal– GivethepaEentallopEonsincludingEmelimitedtrials– PaEentunderstandsconsequencesofdecisions
• EsBmaBngPrognosis– Discusslifeexpectancyandqualityoflife
• ConflictResoluBon– Whathappenswhenthereisadisagreement
ClinicalPracBceGuidelineonSharedDecision-MakingintheAppropriateIniBaBonofandWithdrawalfromDialysis,Nov.1999
SummaryofSharedDecisionMakingGuidelines• AdvancedDirecBves
– ObtainadvanceddirecEvesfromalldialysispaEents
• WithholdingorWithdrawingDialysis– Ethicallythesame
• SpecialpaBentgroups– ReasonablenottoiniEatedialysisonpaEentswithaterminalillnessfroma
non-renalcause
• Timelimitedtrials– Canbeusefulwhenthereisuncertainty
• PalliaBveCare– CanbeofferedatallEmesevenwhenonHD
TrueorFalse:
InESRDpaBentswithwri`enadvanceddirecBves,whentostopdialysisoccursa
majorityoftheBme
HowarewedoingindiscussinggoalsofcareinthesepaBents?
• 30%ofpaEentsolderthan75yearsofagewithdrawfromdialysiswhichisahighpercentageshowingthattheabilitytocounselpaEentsaboutforegoingHDshouldbeacorecompetency
• PhysiciansmaybeunawareofthesenaEonalguidelinesonshareddecisionmakingregardinginiEaEonandwithdrawalofdialysis
• Only22%ofnephrologyfellowsreportedbeingtaughtonhowtotellapaEentthatheorsheisdying– 32%conductedlessthan2familymeeEngsduringtheirtraining
HolleyJL,etal.AmJKidneyDis2003Arnold,R.NEJM2009
AdvancedCarePlanningandHD
• Astudyof400HDpaEentsshowedthatonly51%hadcompletedanadvanceddirecEve
• OverallmostpaEentshadnotdiscussedwishesforspecific
intervenEonsintheeventofapermanentcoma– Only25%haddiscussedCPR– Only18%haddiscussedstoppingdialysis
• EveninthosepaEentsthatcompletedalivingwillandproxy,stoppingdialysiswastheleastoMendiscussedtopic– 69%haddiscussedmechanicalvenElaEoncomparedtoonly31%whohaddiscussedstoppingdialysis
HolleyJL,etal.AmJKidneyDis1999
WhatpercentageofpaBentshadadiscussionwiththeirnephrologistonendoflifeissues?
WhatDoPaBentsWant?ACanadianStudy
• Astudyof584stageIV/VCKDpaEentssurveyedinaCanadianuniversitybasedprogramJanuary-April2008
• 61%regrepedtheirdecisiontostartHD– Whenaskedwhy,52%reportedthatitwastheirdoctor’swish
• 83%wereunawareofpalliaEvecare
• Only38%ofpaEentshadcompletedanadvanceddirecEve
• 52%hadnothaddiscussionsonendoflifecarepreferenceswiththeirphysician– 90%ofpaEentsreportedthatanephrologisthadnothadaendoflife
discussionwiththem
DavisonSN.ASN2010
AjointcollaboraBonbetweenrenalandPCinAustralia• PaEentsenrolledin:
– Pre-dialysisclinic(rouEnepathwaywherebasiceducaEonprovided)– ReferredtoarenalsupporEvecare(RSC)clinic– ApendedneitherclinicbutstartedHD
• Meanadjustedsurvivalwas20monthsintheRSCgroupcomparedto33monthsinthepre-dialysisgroup– However,nodifferenceinsurvivalwhenlookingatpaEents>75yearsof
agewith2ormoreco-morbidiEes(oneofthembeingCHForCAD)
• 32%ofpaEentsintheRSCgroupsurvived>12monthsaMereGFRfellbelow10
• Symptomsandqualityoflifescoreswerestableorimprovedover
EmeandtherewasnodifferencebetweenthepredialysisandRSCgroups
Brownetal.CJASN2015
Summary• ElderlypaEentsonHDwithsignificantco-morbidiEeshavea
highmortalityrateandmaynothaveasurvivaldifferencecomparedtoconservaEvetreatment
• FuncEonalstatusdeclinesdramaEcallyinelderlyNHpaEentswhostartHDanddoesnotimprove
• FuncEonalstatusmaybebepermaintainedbynotstarEngHD• Advancecareplanningoccursinfrequentlybutcanbe
improvedbytrainingothersinshareddecisionmakingguidelines
• PCcollaboraEonwithnephrologyispromisingandcan
potenEallyimprovesymptomsandqualityoflife
BackToOurCase• Youhavea81yearoldmalewithmoderatedemenEa,PVD,CAD,chronicsystolicheartfailurewithanEFof25%,diabetes,andStageVCKDwhomaybeonthevergeofstarEngdialysis
• HisdaughterisinsistentonstarEngHD,because“wehavetodoeverythingyoucandoctortosavehislife”
• HehasmulEpleADLimpairmentsincludingrequiringacanetoambulateandassistancewithdressingandbathing
HowWouldYouApproachThisConversaBon?
WhatActuallyHappened…• YouhavejustpaidverycloseapenEontothistalkandlearnthatHDmaynotbeinthispaEent’sbestinterestandwouldnotimprovehisfuncEonalstatus
• YouobtainaPCconsultaEon
• AMeragoalsofcarediscussion,thegoalsofthedaughteraremoretowardscomfortandshedoesn’twantto“seeherfathersuffer”
• ThedecisionismadetoforgodialysisandheconEnuestoliveacomfortablelifeforthenextseveralmonthsunElheishospitalizedforaheartfailureexacerbaEonandtheneventuallychooseshospice
References1. USrenalDatasystem,USRDS2014AnnualReport2. BeregerJR,HedayaEss,CIASN20123. Carsonetal,CJASN20094. WesibordS,etal.ClinicalJournalofAmSocietyofNephrology20055. KristenJohansenetal,JASN2007:18:2960-66. DeBiaseV,etal.ProlongedconservaEvetreatmentforfrailelderlypaEentswithend-stagerenaldisease:theVerona
experience.NephrolDialTransplant2008;23:1313-1317. CollinsAJ,etal.ExcerptsfromtheUnitedStatesRenalDataSystem2004annualdatareport:atlasofend-stagerenal
diseaseintheUnitedStates.AmJKidneyDis2005;45:Suppl1:A5-A7,S18. Kurellaetal..FuncEonalstatusofelderlyadultsbeforeandaMeriniEaEonofdialysis.NEnglJMed
2009;361:1539-15479. MurtaghFEetal.Dialysisornot?AcomparaEvesurvivalstudyofpaEentsover75yearswithchronickidneydisease
stage5.NephrolDialTransplant2007;22:1955-196210. Kurellaetal.FuncEonalstatusofelderlyadultsbeforeandaMeriniEaEonofdialysis.NEnglJMed2009;361:1539-154711. ClinicalPracBceGuidelineonSharedDecision-MakingintheAppropriateIniBaBonofandWithdrawalfrom
Dialysis,Nov.199912. HolleyJL,etal.FailureofadvancecareplanningtoelicitpaEents'preferencesforwithdrawalfromdialysis.AmJ
KidneyDis1999;33:688-69313. HolleyJL,etal.Theneedforend-of-lifecaretraininginnephrology:naEonalsurveyresultsofnephrologyfellows.AmJ
KidneyDis2003;42:813-82014. Beddhuetal.AJM2000.SimpleComorbidityscalepredictsclinicaloutcomesandcostsindialysispaEents15. Murtaghetal.ESRD:ANewTrajectoyofFuncEonalDeclineintheLastYearofLife,JAGS201116. DavisonSN.EndofLifePreferncesandNeeds:PercepEonsofpaEentswithCKD17. HolleyJL,etal.AmJKidneyDis200318. Brownetal.CJASN2015.CKDinelderlypaEentsmanagedwithoutDialysis:Survival,Symptoms,andQualityofLife