Authors (including presenting author) :
Yeung PY(1), Tang SW(1), Young HKB (1)(2), Wong WYW(2)
Affiliation :
(1) Department of Medicine & Rehabilitation, Tung Wah Eastern Hospital
(2) Quality and Safety Office, Tung Wah Eastern Hospital
Introduction :
Elderly with life-limiting conditions were often admitted with dysphagia. Despite management of acute illnesses, feeding issues persisted. Since February 2021, a management protocol had been established for a coordinated care delivery for patients with feeding problems through shared decision making and a multidisciplinary approach. Patients and families had informed choices of careful hand feeding (CHF) or tube feeding.
Objectives :
To evaluate the effectiveness of the protocol on handling patients with CHF and completeness of in-patient discussion of CHF
Methodology :
A prospective study was conducted from 1 May 2021 to 31 October 2022. All in-patients in the Department of Medicine and Rehabilitation (M&R) with advanced dementia or life-limiting conditions e.g. terminal illness, advanced stage organ failure and multiple complex diagnoses were recruited after swallowing was judged unsafe by speech therapists. The doctor assessed and explained to relatives on risks and benefits of CHF, followed by completion of a CHF Communication Record. The Records were reviewed by the Quality and Safety Office, followed by a post-discharge phone follow up to home carers or old age home (OAH) staff seven days after discharge to understand feeding patterns and difficulties in the community setting.
Result & Outcome :
94 patients (36 women, 58 men) with an average age of 85 were studied. Major principal diagnoses included advanced dementia [n=43, 46%], active cancer (n=16, 17%), end-stage renal failure (n=8, 9%), chronic obstructive pulmonary disease (n=6, 6%), congestive heart failure (n=5 , 5%), pneumonia (n=5, 5%) and stroke (n=3, 3%). 99% cases had DNACPR signed. Clear documentation on the decision reached was observed in all cases.
In all, 45 (48%) patients passed away during the index admission. 49 (52%) patients were discharged. 39% of discharged (n=19) were readmitted within a month. 2% (n=1) and 41% (n=20) passed away in one month and six months respectively.
Among discharged cases, 46 (92%) phone follow-up was successfully conducted. Majority (n=37, 80%) followed diet recommendation, while the rest would slightly add patient’s favor food. Common feeding issues encountered were refusal to open mouth (n=12, 26%) and occasional choking (n=11, 24%).
Satisfactory rate was 100%. Relatives appreciated the option of CHF as an alternative to tube feeding and agreed that it could avoid patients’ suffering and foster dignity. They also found pre-discharge discussion useful and appreciated the arrangement of phone follow up.
The structured management protocol and training could facilitate the roll out of CHF. Communication with family is key, as is documentation of the communication process. The phone follow-up provided a continuity of support from hospital to community. Future enhancement includes recommendation on soft meal choices and recipes by dietitians.
