Novant Health Forsyth rethinks feeding tubes for dementia patients

In late 2010, the palliative-care team at Novant Health Forsyth Medical Center in Winston-Salem, N.C., wanted to find out whether hospital staff were complying with new evidence-based guidelines recommending against the use of feeding tubes in patients with advanced dementia. They found large variations in insertion rates for percutaneous endoscopic gastrostomy (PEG) tubes, depending on the type of attending physician.

When patients at skilled-nursing facilities experienced health problems that made them unable to swallow and they were admitted to the hospital, hospitalists cared for them.

“Hospitalists were requesting over 90% of the permanent feeding tubes,” said Dr. Charles Stinson, clinical director of palliative-care services. “It was an 'aha!' moment for us.” A small percentage of tubes were requested by neurologists and there were rare requests by other specialists.

Once a PEG tube was ordered, gastroenterologists, interventional radiologists and surgeons inserted them. The tubes were thought to prevent malnutrition and delay death in patients with advanced dementia. But guidelines from the American Geriatrics Society and the Alzheimer's Association say the tubes do not achieve those goals. In addition, their use can lead to patient agitation, pressure ulcers, infections, increased aspiration and the need for physical and chemical restraints, according to the guidelines. Both groups recommended hand-feeding instead.

Having provided training on feeding-tube use to staff a few years earlier, the palliative-care team chose a more structured approach. They assembled a multidisciplinary team from various hospital departments and the community.

The team—which included the head palliative-care nurse, the head neurology nurse, a gastroenterologist, clinical dietitian, hospitalist, speech pathologist, stroke navigator, spiritual leader and a community member who had served as family caregiver—started meeting monthly in 2011 to create multipronged educational programs tailored for each target audience.

They held a joint meeting with gastroenterologists and palliative-care physicians, and offered a presentation for hospitalists, interventional radiologists and physiatrists. They designed an online module on swallowing evaluations, oral care and hand-feeding for nursing staff, clinical dietitians and speech therapists. And the hospital showed a video to teach patients and their caregivers about the pros and cons of feeding-tube use, as well as alternative methods of providing nutrition.

“There has definitely been a difference,” said Mary Kiger, a speech pathologist and member of the multidisciplinary team. Before the feeding-tube changes, speech pathologists would note if there was aspiration but would not necessarily make recommendations about what consistency of liquid the patient could tolerate. A PEG tube, she said, was often the default. Now, “people are a lot more knowledgeable and don't just assume a PEG fixes everything,” Kiger said.

Dr. Ramona Rhodes, a contributor to the American Geriatrics Society's guidelines on feeding-tube use, said the hospital's program is on target. “Ultimately the patient, if they are able to, and the family should make the decision they are most comfortable with,” said Rhodes, an assistant professor of internal medicine in geriatrics and palliative care at the University of Texas Southwestern. “It is important that we do our best to counsel family members, but don't force the issue.” The development of a multidisciplinary team is a particularly useful approach, she said, because all stakeholders can offer their unique points of view.

Though Novant Health Forsyth does not yet have data on the results of the program, the palliative-care team is surveying patients' family members.

“The goal of our program was not simply to reduce the number of feeding tubes, but to give patients and families information so that they made the most informed choice, and to make sure staff understood the best practices,” Stinson said. “If we provide clinicians with the evidence and the infrastructure to help facilitate change, constantly assessing and refining the process, with time and patience better outcomes are achieved.”

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