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Quality Improvement Reports

Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7464.491 (Published 26 August 2004) Cite this as: BMJ 2004;329:491

Rapid Response:

Enteral tube feeding in patients with dementia; evidence of common sense

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

Competing interests: No competing interests

27 August 2004
Lewis G Morrison
Consultant Physician in geriatric medicine
Roodlands Hospital Haddington EH41 3PF