Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Practice on yourselves, doctors and nurses.
- Phillip J. Colquitt (27 August 2004)
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Enteral tube feeding in patients with dementia; evidence of common sense
- Lewis G Morrison (27 August 2004)
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QUALITY IMPROVEMENTS IN PERCUTANEOUS ENDOSCOPIC GASTROSTOMY FEEDING, IN PATIENTS WITH DEMENTIA: IS THERE AN EFFECTIVE STRATEGY FOR THE UNITED KINGDOM?
- David S Sanders, Professor Karna D Bardhan (30 August 2004)
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Feeding tubes and cultural shift: strong causal inference from weak study design
- Lorenzo Moja, Nancy Santesso, Camilla Palmhoj, Jeremy Grimshaw (11 September 2004)
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Re: Feeding tubes and cultural shift: strong causal inference from weak study design
- Carol R Monteleoni, Elizabeth Clark, Tamar Kotz (14 September 2004)
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Phillip J. Colquitt, Technician and RN Independent Comment
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Without a doubt one of the least well done procedures in hospitals, is the placement of feeding tubes. From behind the curtains, one hears the distress sounds coming from the patient – the coughs, the gags, the acute respiratory distress. Not to mention the lack of informed consent. Nurses and doctors act like dentists operating without anaesthetic. I often refuse to place tubes, if I think it contravenes ordinary human dignity. If doctors and nurses think it’s such a great idea(tube placement), why not come forward to be practiced on yourselves. Competing interests: None declared |
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Lewis G Morrison, Consultant Physician in geriatric medicine Roodlands Hospital Haddington EH41 3PF
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Monteoloni and Clark’s paper highlights important issues and draws pragmatic but evidence based conclusions about the use of enteral feeding tubes in patients with dementia. One of the basic tenets of medicine is “first do no harm”, but I see an increasing number of patients having tubes inserted where the risks are not adequately considered or properly communicated. The onset of poor swallow in the context of advancing cognitive impairment heralds a poor prognosis. Failing to communicate this and resorting to placement of a feeding tube as a proxy for discussing the real underlying problems is in my view remiss. We appear to live in an age where increasingly it is perceived better to “do everything” than to do the appropriate thing. Additionally, the decision as to whether or not to use feeding tubes may be effectively given to the family or carers to make, placing them in a position of considerable and sometimes intolerable burden, or be taken by a relatively junior member of the medical team. Such decisions must be taken following a full discussion amongst the team caring for such patients in consort with relevant family or carers and taking into account any advance directives regarding the patient or their known wishes. Ultimately the decision rests with the responsible senior clinician, who must be well versed and trained in these issues, or have access to advice from one who is. There is therefore much merit to the model of assessment proposed by the authors. Without necessarily involving the palliative care team, if the algorithm beyond referral to them is followed and patients’ prognosis, capacity and wishes are ascertained, the process of deciding whether feeding tube placement is warranted would often be more considered, and likely result in fewer inappropriate tube insertions. This paper makes recommendations that could and should be followed in any unit that has to deal with patients with dementia who develop swallowing problems. At a time when there is increasing publicity about patients’ rights to ongoing treatment it highlights a very sensitive area in a way that is both evidence based but also applies a good measure of common sense. References: 1. Monteoloni C and Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study BMJ 2004; 329: 491-494 Competing interests: None declared |
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David S Sanders, Consultant Gastroenterologist Royal Hallamshire Hospital, Glossop Road, Sheffield, United Kingdom, S10 2JF, Professor Karna D Bardhan
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Dear editor, I read with interest the manuscript by Monteleoni & Cark. This group have successfully demonstrated a reduction in the number of gastrostomies inserted (in patients with dementia) following the implementation of specific Quality Interventions (QI). There are 2 points which I would like to add to the debate. Firstly how applicable is this observation to the United Kingdom? We have previously reported a high mortality in patients with dementia who have a percutaneous endoscopic gastrostomy inserted (PEG) (1). As a result of this observation we devised a pragmatic strategy to try and improve all aspects of our selection process for PEG insertion (2). Our QI’s are not dissimilar to Monteleoni but also incorporated a one -week waiting list policy prior to a PEG being inserted (Table 1). We found that this additional QI further improved patient selection as it provided an opportunity for all those involved in the decision making process to reflect on the implications of PEG insertion. The nature and long-term implications of a decision to feed mean that carers and relatives have to come to terms with the decision. In addition, particularly ill patients may succumb during this ‘cooling off’ period. Like Monteleoni (but in a UK setting) we were able to demonstrate a significant reduction in the number of PEG’s inserted in patients with dementia (2). The final issue which is perhaps harder to quantify, is the practice by nursing homes to preferentially accept patients with PEG tubes. This practice is linked to a greater level of remuneration (3,4). In addition, the insertion of a PEG may potentially reduce the length of stay in hospital and alleviate the pressure on acute medical beds. However, these external economic and logistic forces may not be in the patient’s best interest (3,4). In the UK at least, it is only when this practice is addressed that we will see a global decline in referral for gastrostomy insertion in patients with dementia. Table 1: Percutaneous Endoscopic Gastrostomy referral strategy (2,3) 1. Standardise PEG referral form including concomitant disease 2. Endoscopy nurse triage and dissemination of published evidence 3. Gastroenterological review where necessary 4. Holistic and multidisciplinary approach 5. Advise against PEG feeding in patients with dementia 6. One-week waiting list policy References 1. Sanders DS, Carter MJ, D`Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in Percutaneous Endoscopic Gastrostomy: a worse outcome in patients with dementia. Am J Gastroenterol 2000;95:1472-5. 2. Sanders DS, Carter MJ, D`Silva J, James G, Bolton RP, Willemse PJ, Bardhan KD. Percutaneous Endoscopic Gastrostomy: a prospective audit of the impact of guidelines in 2 district general hospitals in the United Kingdom. Am J Gastroenterol 2002;97:2239-45. 3. Sanders DS, Anderson AJ, Bardhan KD. Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia. Clin Med 2004;4:235-41. 4. Tham TCK, Taitelbaum G, Carr-Lock DL. Percutaneous endoscopic gastrostomies: are they being done for the right reasons? Q J Med 1997;90:495-6. Competing interests: None declared |
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Lorenzo Moja, Research Fellow Effective Practice and Organisation of Care Group, University of Ottawa, Ottawa, Canada K1N 6N5, Nancy Santesso, Camilla Palmhoj, Jeremy Grimshaw
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Monteleoni and Clark describe a clinical quality improvement initiative to reduce feeding tube placement in patients with dementia. They concluded that “interdisciplinary teamwork and focused educational effort can rapidly produce change in practice”.(1) We would like to point out some limitations that likely affect their conclusion. As specified by the authors this is an uncontrolled before and after study (UCBA). UCBAs are intrinsically weak evaluative designs, as secular trends and sudden changes make it difficult to attribute observed changes to the intervention. These threats to internal validity are so plausible that Cook and Campbell describe the results of UCBAs as “generally uninterpretable”.(2) They also argue that investigators using such quasi experimental methods need to rule out all plausible rival hypotheses before any causal relationship can be inferred. We believe that there are many plausible rival hypotheses that could also explain the study results that have not been excluded by the investigators (e.g. rotation of new medical residents). The authors claim that the multidisciplinary intervention “led to a 'cultural shift'”. The only outcome measured is the number of feeding tubes placed. We did not find any proof in the literature that this outcome, nor the observation of informal and formal talk, could be used as a proxy for medical culture. Use of a questionnaire on attitudes, beliefs and barriers might provide a more valid measure of a ‘cultural shift’. Due to the weakness of the design and of the outcome measured, we believe the authors are overstating the causal relationship in their conclusion and the mechanism of action of the intervention. 1. Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ. Aug 28 2004;329(7464):491-494. 2. Cook TD, Campbell DT. Quasi-experimentation: Design and Analysis Issues for Fields Settings. Chicago: Rand McNally; 1979. Competing interests: None declared |
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Carol R Monteleoni, coordinator, speech-language pathology Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, Elizabeth Clark, Tamar Kotz
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We were interested to read your critique of our quality improvement report. Our QI activity was not designed as a clinical study. In accordance with the principles of rapid cycle quality improvement, we initially obtained data to confirm a problem which we suspected existed. We then designed and rapidly implemented interventions to address the problem. We then repeated our initial data collection to determine if any change had been made. It was not within the scope of our activity to understand the exact causality of the change. With respect to the “cultural shift,” Mr. Moja’s point is well taken. As we made our daily rounds in the hospital, we sensed a change in culture, evidenced by more open discussion of the issues surrounding feeding tubes, end-of-life care, adherence to advance directives, and consideration of medical futility. This was an impression, but not a hypothesis which was formally measured. In this way, we agree that one cannot conclude that our intervention caused a “cultural shift”. Mr. Moja et al. suggest the use of a questionnaire on physician attitudes, beliefs and barriers as a valid measure of cultural shift. Anecdotally, colleagues at another NYC hospital surveyed physicians’ knowledge and attitudes regarding the appropriateness of tube feedings in patients with dementia. They found that, while respondents knew the literature, did not believe that tubes would benefit their demented patients, and, if they themselves were patients, would not opt for tubes, they continued to place tubes in demented patients. Thus the issue is even more complex, in that knowledge and attitudes are not the sole determinants of practice. Our hope is that our report will be a springboard to address the myriad issues surrounding the practice of inserting medically futile feeding tubes in patients with advanced dementia. Competing interests: None declared |
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