J.K.H. Luk1, T.C. Chan1, F.H.W. Chan1
Department of Medicine and Geriatrics, Fung Yiu King Hospital, Pokfulam, Hong Kong.
Corresponding Author: T.C. Chan, Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong, Email: firstname.lastname@example.org, Tel: 28556133, Fax: 28196182
One of the natural trajectories of many disease process is eating problem with swallowing difficulty (1). In Hong Kong, unless there is a valid advance directive (AD) or advance care planning (ACP) declining enteral feeding, healthcare professionals often feel compelled to start enteral feeding. This explains partly the popularity of enteral feeding among older people in Hong Kong (2). Careful hand feeding (CHF) has been advocated as an alternative for older people with eating problems. The American Geriatrics Society (3) emphasizes that CHF should be offered in advanced dementia patients as it is at least as good as enteral feeding for the outcomes of death, functional status, and comfort (4). It should be considered in end-of-life care (5).
CHF program has been started since Feb-2017 in a geriatric step-down hospital in Hong Kong. A working group including Geriatrician, nurses, speech therapists (ST) and dietien is established to implement the program. In the program, older patients who are in end of life (EOL) stage will be offered CHF if they have dysphagia and/or poor feeding. A thorough discussion is made with patients and/or family members on the pro-and-cons of enteral feeding and CHF. STs recommend the most suitable consistency of food and technique to feed the patients while dietitians prepare the specific food. Family members or ward nurses will perform the feeding. Family members are taught to observe signs of choking and aspiration.
One hundred and forty-five patients (age 91.5+7.5) entered the program from Feb-2017 to Dec-2019. The demographics are shown in table one. One hundred and fifteen (79.3%) patients are nursing home residents. The principal diagnoses of patients included advanced dementia, active cancer, neurodegenerative disease, end-stage organ failure, and stroke. Prior to admission, most patients lived in nursing homes with poor mobility and a severely impaired functional state.
The reasons for considering enteral feeding initially were mainly dysphagia (92.6%). After CHF, sixty-six (45.5%) patients have satisfactory oral intake. Seventy-four (51.1%) patients passed away during the index admission. Seventy-one (48.9%) patients recovered and were discharged. No participant developed aspiration pneumonia after entering the program.
*Value are Mean+standard deviation or median (interquartile range)
At present, CHF has not been practised widely in Hong Kong. The patients under CHF have to be fed slowly and cautiously, making it a very labour-intensive task. Nursing staff worry about medical-legal consequences should the patients develop aspiration after CHF. To execute the program successfully requires a change of culture and practice of the hospital team. A working group with members from geriatrician, nurses and allied health professionals plays the important driving force for the program. As CHF involves change in usual practice and culture, training is imperative for lessening worries of the health care team. In the program, doctors play a pivotal role in discussion with relatives and seek consensus with them to start CHF. The distinct endorsement by doctors gives confidence to the nursing staff to carry out CHF.
This program shows that CHF is feasible in a geriatric step-down hospital. It fosters comfort and dignity of the dying patients and acknowledges the views of patients and family members. Further development of CHF in hospital units taking care of older patients with EOL issues is recommended.
Conflict of interest: Nil
1. Mitchell SL, Teno JM, Keily DK, et al, “The clinical course of advanced dementia”, N Engl J Med 2009; 361:1529-1538
2. Luk JK, Chan WK, Ng WC, et al. Mortality and health services utilization among older people living in residential care homes suffering from advanced cognitive impairment. Hong Kong Med J 2013;19:518-24
3. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014 Aug;62(8):1590-3
4. Hanson LC, Ersek M, Gilliam R, et al. 2011. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc 59:463-472
5. Downar J, Moorhouse P, Goldman R, et al. Improving End-of-Life Care and Advance Care Planning for Frail Older adults in Canad. J Frailty Aging 2018; 7: 240-246