End-of-Life Choice, Palliative Care and Counseling

Posts Taggednursing home

Time Magazine’s Cover Story on End-of-Life Care

“How to Die” reads the cover of the June 11th issue of Time Magazine. Joe Klein writes about his parents’ approaching the end of life, and about the dramatic improvement in their care when they transitioned to a facility without incentives for unnecessary interventions.

The full story will soon (or immediately, for subscribers) be available online, and at newsstands later this week. Watch Joe Klein’s discussion now at Time.com.

Find Yourself a Good Hospital

Since November, when the United States Council of Catholic Bishops (USCCB) voted to change the Ethical and Religious Directives for Catholic Health Care, I have written frequently how the new policy could result in continued tube feeding for thousands of unconscious and severely demented patients in Catholic hospitals and nursing homes. Newly released research highlights the problem.

Representatives for Catholic hospitals downplay it. Sister Carol Keehan, executive director of the Catholic Health Association, said she doesn’t see much conflict between patients’ and families’ end-of-life wishes and the new directive. “Advance directives are held in great respect in Catholic hospitals,” she said in a recent interview. “Some might like to say there’s a terrible problem, but there isn’t.”

Catholic hospitals have attracted unwanted attention over this change in policy, and they assert the attention is unwarranted, because mentally compromised patients are in nursing homes, not hospitals. Alan Sanders, director for the Center for Ethics at St. Joseph’s Hospital in Atlanta, says that as an acute care facility, St. Joseph’s is unlikely to encounter a decision to remove a feeding tube from a patient in a persistent vegetative state.

Well, not exactly. Recent evidence indicates hospitals, not nursing homes, are the usual site of decisions to insert feeding tubes. A 2003 study reported more than one-third of nursing home residents with advanced dementia have a feeding tube, and a new study shows whether they get one depends much on the hospital they’re admitted to. The Providence Journal reports,

Dr. Joan M. Teno, the chief author of the study, said the results show that it’s not the wishes of the patients that are driving these decisions. “It really is the hospital culture that is determining this…. This doesn’t look like a process that is respecting patient choice.”

Hospitals vary widely in their incidence of feeding tube insertion. Even hospitals in the same community can differ greatly in how often they place a feeding tube in demented patients. In spite of evidence proving the tubes increase suffering and do not prolong life, some hospitals have even increased their utilization in recent years.

The survey of more than a quarter-million hospital admissions from 2000 to 2007 showed that during the last two years of the survey, Roger Williams Medical Center and Kent Hospital stopped using the tubes.

Nationally, 12 percent of the hospitals fell into the same category.

But at St. Joseph Health Services of Rhode Island, which runs St. Joseph Hospital and Our Lady of Fatima Hospital, use of the feeding tubes actually increased during the last two years of study – 7.7 percent of patients got them, up from 6.9 percent during the broader period of 2000 to 2007.

That’s more than the national rate of 6.2 percent in 2007, an average that has been declining since 2000.

Teno said that within the past year, U.S. bishops decreed that feeding tubes must be given for all patients – Catholic and non-Catholic – who have lost the ability to eat or drink, unless they are actually close to death.

That philosophy, “I think, partially explains the results with St. Joe’s, being a Catholic health-care system,” said Teno.

The study illuminates other factors influencing feeding tube insertion. 

For-profit hospitals and larger hospitals were more likely to use the tubes, Teno and her colleagues found. Black and Hispanic patients were nearly twice as likely to get them as whites.

Teno said she is concerned that Catholic hospitals may be trying to override the wishes of patients when they insist on feeding tubes.

Advance care planning, the study says, also has an important role in reduction of potentially unnecessary procedures. Although it’s not fool-proof (590 patients were given feeding tubes despite written orders to forgo artificial hydration and nutrition!) patients with a living will and durable power of attorney for health care were far less likely to have tubes inserted.

Once again, our advice proves sound: prepare an advance directive, talk to your doctor, talk to your loved ones. Because you can’t be sure whether the policies of a for-profit hospital, or a Catholic one, might impose an unwanted feeding tube, consider adding this Sectarian Health Care Directive addendum. And help Compassion & Choices set enforceability standards for advance directives. We want feeding tube decisions to follow your wishes, not institutional policies of profit or doctrine.