Feeding of severely demented patients in institutions: interviews with caregivers in Israel

Mapping and understanding the decision-making process for providing nutrition and hydration to people living with dementia: a systematic review

BACKGROUND

This systematic review aimed to explore the process of decision-making for nutrition and hydration for people living with dementia from the perspectives and experiences of all involved.

METHODS

We searched CINAHL, the Cochrane Library, EMBASE, MEDLINE and PsycINFO databases. Search terms were related to dementia, decision-making, nutrition and hydration. Qualitative, quantitative and case studies that focused on decision-making about nutrition and hydration for people living with dementia were included. The CASP and Murad tools were used to appraise the quality of included studies. Data extraction was guided by the Interprofessional Shared Decision Making (IP-SDM) model. We conducted a narrative synthesis using thematic analysis. PROSPERO registration number CRD42019131497.

RESULTS

Forty-five studies were included (20 qualitative, 15 quantitative and 10 case studies), comprising data from 17 countries and 6020 patients, family caregivers and practitioners. The studies covered a range of decisions from managing oral feeding to the use of tube feeding. We found that decisions about nutrition and hydration for people living with dementia were generally too complex to be mapped onto the precise linear steps of the existing decision-making model. Decision-making processes around feeding for people living with dementia were largely influenced by medical evidence, personal values, cultures and organizational routine. Although the process involved multiple people, family caregivers and non-physician practitioners were often excluded in making a final decision. Upon disagreement, nutrition interventions were sometimes delivered with conflicting feelings concealed by family caregivers or practitioners. Most conflicts and negative feelings were resolved by good relationship, honest communication, multidisciplinary team meetings and renegotiation.

CONCLUSIONS

The decision-making process regarding nutrition and hydration for people living with dementia does not follow a linear process. It needs an informed, value-sensitive, and collaborative process. However, it often characterized by unclear procedures and with a lack of support. Decisional support is needed and should be approached in a shared and stepwise manner.

A Report of an Investigation of End-of-Life Care Practices in Health Care Facilities and the Influences on those Practices

In 1992, 82.2% of deaths in Alberta occurred in acute care hospitals or continuing care facilities. This paper outlines the end-of-life care of adult in patients who died that year in four such facilities (n=137). CPR was an infrequent end-of-life treatment modality (2.9%), in stark contrast to the extensive use of other medical technologies. Almost every inpatient (94.2%) died with one or more technologies in continuous operation. Although reasons were infrequently given, the desire to promote patient comfort was the most frequent influence on end-of-life technology use. The findings of this study raise issues for debate and further investigation. Chief among these issues is whether or not medical technologies promote comfort during the dying process.

Preparedness for End of Life-a Survey of Jerusalem District Nursing Homes

OBJECTIVES

To evaluate the quality of end-of-life (EOL) care in nursing homes.

DESIGN

Survey and semistructured interviews.

SETTING

Jerusalem district nursing homes.

PARTICIPANTS

Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207).

MEASUREMENTS

Qualitative analysis of semistructured interviews and statistical analysis of questionnaires.

RESULTS

Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family's preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents.

CONCLUSION

Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement.

Long-Term Tube Feeding Practices and Involvement of Nurses in Tube Feeding Decisions

Le gavage est fréquemment utilisé pour supporter la vie à long terme. Actuellement, aucune distinction est faite entre le gavage à court terme et celui à long terme, ce dernier étant un remplacement de l'habilité de manger sur une base continuelle et permanente. Très peu de recherches ont été faites sur le gavage à long terme. Conséquemment, les implications et pratiques du gavage à long terme demeurent indéterminées. Les dossiers hospitaliers de dix patients ayant été alimentés par gavage à long terme ont été examinés pour répondre à des questions prédéterminées. Le rapport de ce travail inclut plusieurs sujets: les types de solutions pour alimenter les patients, les types de tubes, les différentes méthodes utilisées, les diagnostics médicaux et les raisons qui justifient ce type d'alimentation, sans oublier l'implication des infirmières et des autres intervenants dans la décision d'initier et de continuer le gavage. On a pu démontrer que le gavage permettait la survie du patient à très long terme. Cependant, en dépit de l'amélioration de la nutrition, aucun progrès n'a pu être constaté ni sur le plan des capacités physiques et mentales des patients, ni sur le plan de leur prise en charge. Maintenir en vie semble être le seul but du gavage à long terme.

Feeding difficulty in older adults with dementia

AIMS AND OBJECTIVES

To use concept analysis to identify characteristics of feeding difficulty and its antecedents and consequences that provide direction for assessment and management.

BACKGROUND

Feeding difficulty is often recognised as a common problem for older adults and is associated with weight loss, poor nutrition and risk for aspiration pneumonia. The cognitive impairment found in persons with dementia impairs the ability of these adults to complete motor and perceptual tasks required for eating and often prevent the older adult from accepting help with feeding from caregivers.

DESIGN

Systematic review.

METHODS

In 2006, literature searches using keywords (feeding, eating, nutrition, malnutrition, feeding assessment, dementia, ageing and concept analysis, dementia and feeding and excluding enteral feeding, tube feedings, PEG and enteral nutrition) were done in Medline, CINHAL, AGELINE and Social Science Full Text. Seventy relevant articles in English were found. After a review of the relevant articles, concept analysis was used to develop a definition of feeding difficulty, its defining characteristics and to delineate feeding difficulty from its antecedents and consequences.

RESULTS

Feeding difficulties arise at the interface between the caregiver strategies to assist the older adult with getting food into the mouth and chewing and swallowing food. A model of feeding difficulty delineates the antecedents and consequences of feeding difficulties.

CONCLUSIONS

The conceptual model of feeding difficulties provides a strong and clear organising structure for research that can be used to developed evidence based guidelines for practice.

RELEVANCE TO CLINICAL PRACTICE

The conceptual model provides directions for assessment of feeding difficulties and their antecedents. The model can be used to identify interventions that address antecedents of feeding difficulty (risk factors) and different types of feeding difficulties.

Feeding nursing home patients with severe dementia: a qualitative study

AIM

To describe the nature of problems nurses face when feeding nursing home patients with severe dementia, and how they deal with these problems.

BACKGROUND

In our study on starting or withholding artificial nutrition and hydration for nursing home patients with dementia, we found that many problems in feeding arose (long) before any decision was made about artificial feeding, namely from the first moment a patient needed help with meals. Because 'ordinary feeding' was experienced as a daily recurring problem for nurses, we decided to investigate this within the study.

METHODS

Participant observation by two researchers in two Dutch nursing homes.

FINDINGS

Nurses interpreted the aversive behaviour of patients differently, and a link between interpretation and responses (stop or continue feeding) was observed. Differences in interpretation with regard to the same patient were observed in nurses in five of the seven units. Only in three units did nurses discuss their different interpretations in an attempt to find out why a patient avoided food and fluids and how to deal with these problems.

CONCLUSIONS

Nurses' interpretations of aversive behaviour of patients differ. No definite conclusions can be drawn about the causes of the aversive behaviour observed, because they cannot be verified. We recommend that interpretations of the behaviour of particular patients should be discussed by nurses with physicians, other disciplines and the patient's family to obtain more insight into all its possible causes and to determine together the most likely interpretation and appropriate way in which to deal with the aversive behaviour. This would give nurses more confidence and improve the quality and continuity of care provided. To structure the search for possible causes of aversive behaviour, we developed a framework of causes of aversive behaviour and domains of functioning.

Perceptions of autonomy in the care of elderly people in five European countries

The focus of this article is perceptions of elderly patients and nurses regarding patients' autonomy in nursing practice. Autonomy is empirically defined as having two components: information received/given as a prerequisite and decision making as the action. The results indicated differences between staff and patient perceptions of patient autonomy for both components in all five countries in which this survey was conducted. There were also differences between countries in the perceptions of patients and nurses regarding the frequency with which patients received information from nursing staff or were offered opportunities to make decisions. This is the second of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.

Supporting life through tube feeding: factors influencing surrogate decision-making

Un grand nombre de personnes ont besoin d'une sonde au cours de la dernière étape de leur vie. Par ailleurs, la décision du maintien des fonctions vitales revient souvent à une autre partie. Lorsque les membres d'une famille sont tenus de prendre cette décision pour un patient incompétent, quels facteurs influenceront leur choix? Une étude de cas et un sondage ethnométhodologique ont révélé clairement et en détail les facteurs ayant influencé une femme devant décider si les fonctions vitales de sa mére en état d'incapacité totale et de grave débilité devaient être maintenues au moyen d'une sonde pour gavage. La décision était difficile à prendre et survenait à un moment critique. Malheureusement, les facteurs ayant eu la plus forte influence furent les suivants: a) le besoin pressant d'une décision en raison d'un décès imminent; b) une lacune quant à la connaissance des valeurs et des préférences de la mère au sujet du maintien de ses fonctions vitales au moyen d'une sonde pour gavage; c) un manque de connaissance quant à la réalité de l'alimentation par sonde; et d) la croyance que cette mesure ne prolongerait pas la vie ni la souffrance de la mère. De plus, neuf autres facteurs, moins importants, ont été déterminés. Cette étude est principalement axée sur l'amélioration de la sensibilité des professionnels de la santé vis-à-vis de l'angoisse qu'éprouvent les gens à décider de maintenir les fonctions vitales d'un proche et du mode de décision en tant que tel.

The role of CNSs in promoting elderly patients' autonomy in long-term institutions: problems and implications for nursing practice and research

Autonomy has become an important focus within healthcare. Elderly patients, however, are often denied the right to independent decision making on grounds of incompetence and incapacity. In long-term institutions there are several ways in which the clinical nurse specialist can promote the autonomy of elderly patients. This article provides an overview of the concept of autonomy and discusses some of the problems in its realization in long-term nursing institutions. It also outlines strategies for supporting autonomy in elderly patients and concludes with a discussion of the implications of autonomy to nursing practice and research.

Assisting demented patients with feeding: problems in a ward environment. A review of the literature

A critical review of the literature on assisting demented patients with feeding difficulties identifies that care at mealtimes is often task-centred, causing stress in both patients and staff and inadequate patient care. Nurses may even be inducing dependency in this vulnerable patient group. The staff to whom this care is most often delegated do not receive sufficient education or training to enable them to achieve a sufficient degree of empathy with the patient although there is evidence in the literature to suggest that this is a necessary requirement. It is also apparent that nurses use inadequate assessment criteria, perhaps due to the fact that there is an element of commonality in the feeding behaviour of demented patients which nurses feel they have seen many times and are able to deal with. The introduction of primary nursing, increased education of nursing assistants and improved assessment procedures to combat these problems are recommended. The process of change is briefly outlined and in conclusion some areas for future research are stated.

Nurses' narratives about using coercion in psychiatric care

To illuminate nurses' experience of using coercion against psychiatric patients, a phenomenological hermeneutic study was conducted with seven registered nurses and seven enrolled mental nurses. The findings revealed that these nurses desired to be seen by themselves, their co-workers and patients as doing good, being good and providing good care but they experienced the use of coercion as not good. This conflict made it difficult for these nurses to question the use of coercion and consider alternative solutions. The theory of change by Watzlawick et al. (1974) served as a theoretical framework for the interpretation of all interviews regarded as one text. In order to explore alternatives to the use of coercion in psychiatric care, nurses need assistance to step outside the traditional way of regarding coercion in psychiatric care and seek to create new solutions.

Feeding difficulty in elderly patients with dementia: confirmatory factor analysis

The latent structure of feeding difficulty in elderly patients with dementia was investigated using multivariate statistical techniques including exploratory and confirmatory factor analysis. A survey design of 345 elderly patients with the diagnosis of dementia using a questionnaire completed by key workers and primary nurses, was used in local psychogeriatric and continuing care of the elderly facilities. Feeding difficulty and nursing intervention were estimated followed by fitting of latent variable models of feeding difficulty to the data using structural equation modelling. Three models of feeding difficulty in elderly patients with dementia, with 2, 3 and 4 factor structures respectively were compared. All three models showed a good fit to the data as assessed by several standard criteria. The 3 and 4 factor models, however, showed significantly better fit than the 2 factor model. The 4 factor model introduced a latent variable of "oral difficulty" with feeding which merits further investigation. This study demonstrates the possibility of developing reliable and validated scales for the assessment of feeding difficulty in elderly patients with dementia.

Retired registered nurses' stories about being in ethically difficult care situations

Twelve retired nurses were asked to narrate a care situation in which it had been difficult for them as nurses to know what was the right and good thing to do. The transcribed interviews were examined by content analyses. Physicians were the central coactors in the nurses' stories. Colleagues were seldom mentioned. Other ward staff were mainly called "the girls". The patient was central and referred to with respect. All the nurses focused on experiential learning. Guiding ethical principles are listed.

Patients' narratives concerning good and bad caring

Narratives from patients (n = 80) and patients' relatives (n = 12) were collected to illuminate experiences of good and bad caring episodes and to obtain descriptions of good caring. Narratives describing good caring included such task aspects as swift and correct assessment and access to information. Aspects less frequently mentioned were, for example, being given time, receiving pain relief and good food. Relationship aspects mentioned; having an interest shown in the care, being taken seriously and being cared about. There are parallels regarding relationship aspects between the narratives concerning good and bad caring episodes; for example what was praised in the good caring narratives was criticized in those describing bad caring. Such parallels were being/not being trusted, being/not being believed and being/not being respected. The narrations concerning bad caring were more specific and more vivid than those about good caring. The authors' interpretation was that the bad episodes were unexpected and very painful and therefore remained imprinted in the patients' memories. The descriptions of good caring included relationship aspects in only 34 cases, task aspects in only five cases and a combination of both in 50 cases. The ultimate purpose of the study was to obtain a basis for the development of a policy for good caring founded on patients' experiences. It is desirable that further studies be undertaken within various clinical specialties which would also take into consideration medical, social and cultural perspectives.

The stories of physicians, registered nurses and enrolled nurses about ethically difficult care episodes in surgical care

Twenty physicians, 19 registered nurses (RN), and 20 enrolled nurses (EN) working in surgical care in Sweden narrated their experiences of being in ethically difficult care situations. All three professional groups disclosed a strong wish to help patients. The narrations of the physicians and the ENs indicated that they were very much involved in their patients, while most of the RNs' stories were narrated from a distanced onlooker's perspective and disclosed a lot of moral outrage, mainly directed towards physicians. The physicians were the only group that emphasized the importance of acting in accordance with science and proven experience. Like RNs they emphasized the importance and difficulty of telling the truth to the patients and their families and being open to one's own and others' harsh experiences. RNs and ENs emphasized the patient's right to a death with dignity and the difficulties connected with being with dying patients, and they also described feelings of powerlessness and neglect of patients related to a heavy work load. ENs narrated difficulties related to providing patients with individualized but fair care.

Practical ethical issues related to the care of elderly people with dementia

The care of elderly people with dementia poses ethical problems in several respects. This paper considers the problems in relation to treatment, withdrawal of treatment (including nutrition and hydration) in terminal care, and consent to involvement in research. It is ultimately the responsibility of the physician to take the decision about whether or not to proceed with treatment, according to the best interests of the patient, but nurses, families and significant others can be involved in making the decision. When withdrawal of treatment or withdrawal of nutrition and hydration in the terminal stages of dementia are being considered it is necessary to take into account the nature of the treatment, whether or not it is extraordinary, and the goals of continued nutrition. In some circumstances it may be possible for them to be withdrawn. Only research which is aimed at evaluating treatment for dementia may involve subjects who are suffering from dementia.

Soigner des personnes âgés souffrant de la démence pose plusieurs problèmes éthiques. Cet article considère les problèmes concernant le traitement, cessation de traitement (y inclus nutrition et hydration) dans la phase terminale, et consentement de participation dans les recherches. C'est ultimement la décision du docteur si oui ou non de continuer avec le traitement selon les meilleurs intérêts du malade, mais les infirmiers/ères, les familles et les personnes importantes autour du malade peuvent jouer un rôle dans les décisions. Si la cessation de traitement ou cessation de nutrition et hydration dans la phase terminale de démence est envisagée il est nécessaire de tenir compte de la nature du traitement, s'il est 'extraordinaire' ou non, et le but de nutrition si on continuait. Dans quelques circonstances il est possible de les discontinuer. Seuls les recherches qui ont pour but d'évaluer les traitements pour la démence peuvent utiliser des personnes souffrant de démence.

Die Pflege von älteren Personen mit Demenz stellt einige ethische Probleme. Dieser Artikel betrachtet die Probleme in Beziehung auf die Pflege, Zurückziehung von Pflege (auch von Nahrung und Getrank) der Sterbenden und der Entscheidung, in der Forschung beteiligt zu sein. Der Arzt hat die schlussendliche Verantwortung über die Entscheidung ob mit der Pflege weitergefahren werden soll oder nicht nach dem besten Interesse der Patienten. Aber das Krankenpflegepersonal, die Familie und bedeutende Andere können auch an dieser Entscheidung teilnehmen. Wenn es sich um Zurückziehung der Pflege, oder Zurückziehung von Nahrung oder Getrank in der Sterbepflege von Personen mit Demenz handelt, is es nötig, das Wesen der Pflege und die Ziele einer fortfahrenden Nahrung zu kennen. In gewissen Fällen ist es möglich, diese zurück zu ziehen. Es sollen nur Patienten mit Demenz an Forschungen teilnehmen die über die Pflege der Demenz einschätzt.

Ethical reasoning concerning the feeding of severely demented patients: an international perspective

Structured interviews were held with 149 registered nurses in seven countries in America, Asia, Australia and Europe concerning the feeding of severely demented patients who do not accept food. The most common reasons for nurses being willing to change their decision to feed or not to feed were an order from the medical head, a request from the patient's husband and/or the staff meeting. There was a connection between the willingness to feed and the ranking of ethical principles. Nurses who were most prone to feed the patient most often gave a high rank to the ethical principle of sanctity of life, while those who primarily chose not to feed the patient gave a high rank to the ethical principle of autonomy. All nurses stressed the ethical principle of beneficence.

Ethical concerns in a long-term tube feeding study

Five ethical concerns about decision-making in relation to tube feeding were determined through secondary analysis of findings from a chart review study examining long-term tube feeding practices. The five ethical concerns are: (1) who should make the decision to tube feed? (2) how should tube feeding decisions be made? (3) what are valid reasons for initiating and continuing tube feeding? (4) is it permissible to withdraw tube feeding once it is initiated? and (5) is tube feeding an effective and appropriate life supporting technology? Ethical concerns are described, using examples from research data. Implications for health care follow.

The sucking behaviour of two patients in the final stage of dementia of the Alzheimer type

Two patients in the final stage of dementia of the Alzheimer type (DAT), who could no longer be given nutrition by assisted feeding, were given fluids by means of the sucking ability they still retained. They sucked more slowly under nutritive than under non-nutritive sucking conditions. The sucking efficiency of one of them improved during training. The status of the patients in the final stage of their dementia differed from one another, which might explain the difference in outcome. It is therefore suggested, that the use of the patients' sucking ability could serve as a complement and/or an alternative feeding technique when assisted spoon-feeding becomes extremely difficult or impossible. It is considered to be more gentle and natural than the present feeding techniques.

Towards basic nursing information in patient records

Four key concepts for good nursing care and a list of key words for nursing documentation in patient records were established and to some extent tried in clinical practice in Sweden. The method consisted of the following steps: extensive literature review, review of nursing records, development of a list of key words on two levels, a first level corresponding to the nursing process, and a second level consisting of subdivisions for possible use in practice, use and assessment in clinical practice by nurses and students, expert panel judgement and refinement of the key words including an examination of semantic accuracy of the Swedish key words by an expert in Nordic languages. The proposed key words are presented both in English and Swedish and explanations, comments and references are given. The version of key words presented here is subject to further testing for possible modifications.

International comparison of long-term care: the need for resident-level classification

Differences between long-term care facilities in Stockholm (1134 residents) and New York (95,000 residents statewide) were examined. The comparison employed a resident classification system, Resource Utilization Groups (RUG-II), which links individuals' characteristics to resource use. Distributions of Activity of Daily Living functionality and RUG-II categories demonstrated significant differences between these two populations, with the Stockholm facilities more akin to the heavier care skilled nursing facilities in New York. These differences may indicate different uses of long-term care beds in the United States and Sweden and demonstrate the need for resident-level classification systems in cross-national studies.