Magazine article Clinical Psychiatry News
Dementia Patients Get Feeding Tubes Instead of Palliation
Patients with advanced dementia are not recognized as having a terminal condition and so do not receive adequate palliative care in the final phase of the illness, reported Dr. Susan L. Mitchell and her associates at Beth Israel Deaconess Medical Center, Boston.
Lacking advance directives that limit aggressive care, many patients with late-stage dementia undergo painful, unnecessary interventions, including the insertion of feeding tubes, in the weeks before death.
Often, their distressing signs and symptoms, such as fever and shortness of breath, are not recognized or managed adequately. And they are more likely than other terminally ill patients to have markers that are generally associated with poor quality of care, such as pressure ulcers, the use of restraints, and treatment with antipsychotic medications, the researchers said.
These are the findings of a study comparing end-of-life care between 1,609 patients with advanced dementia and 883 patients with terminal cancer who were treated at 643 nursing homes in New York State between 1994 and 1997. An estimated 90% of the 4 million Americans with dementia are treated in nursing homes in their final months (Arch. Intern. Med. 164:321-26, 2004).
Less than a month before their deaths, only 66 (4%) of the patients with advanced dementia were recognized as having a terminal illness.
Patients with advanced dementia were eight times less likely to have a Do Not Resuscitate order than were cancer patients in the month preceding death. Only 55% of those with dementia had DNR orders, compared with 86% of the cancer patients, at their last medical assessment, Dr. Mitchell and her associates reported.
Similarly, only 1% of the dementia patients had Do Not Hospitalize orders. Patients with Do Not Hospitalize orders usually are effectively managed with conservative treatment in their own beds, while those who are moved to hospitals usually undergo a disorienting transfer and more invasive medical care in the hospital.
Advanced care planning that limits transfer to acute care hospitals therefore would greatly improve palliation at the end of life for patients with advanced dementia, Dr. …