Interdisciplinary Risk Management Protocol for Feeding Problems in Severely Frail Elders with Advanced Neurodegenerative Diseases – Careful Hand Feeding Program

Abstract Description

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Authors (including presenting author) :

HO SKS(1), WONG G(2), LI HY(1), WONG CK(1), MAK PKF(1), NGAN C(2) KNG PLC(1)

Affiliation :

(1)Department of Medicine and Geriatrics, RTSKH (2)Department of Speech Therapy, RTSKH

Introduction :

Choosing between oral feeding and tube feeding in elders frequently involves ethical dilemmas and creates conflicts among healthcare providers, patients and families. Careful hand feeding (CHF) is an alternative means to balance quality of life and manage aspiration risks. Yet, barriers to its application include lack of communication among speech therapists, nurses, doctors and carers to align goals and medicolegal concerns. Additionally, CHF skills are necessary to empower ward staff and carers.

Objectives :

To manage feeding problems in elderly at advanced stages of irreversible illnesses with severe dysphagia by (a) developing an interdisciplinary risk management protocol for communication and documentation of goals of care and risks, and (b) empowering ward staff and carers with CHF skills.

Methodology :

Geriatricians, speech therapists and geriatric nurses developed guidelines on CHF in August 2016. In-service training was organised for frontline staff. Target patients were elderly assessed to have high aspiration risk by Speech Therapist, but families preferred non-tube feeding. Feeding care plan consisted of communicating to carers of feeding options, risks and outcomes, then documented using Advanced Care Planning (ACP). Carers were educated on feeding techniques. Further carer empowerment included flexible visiting hours and feeding regimen, support from community team to residential care homes upon patients’ discharge. A satisfaction survey among patients’ families was conducted.

Result & Outcome :

105 patients mainly suffering from advanced dementia (65, 62%) and stroke (11, 10.5%) were recruited. Increasing trend of carers prefer CHF; 15(14.3%) in 2016, 24(22.9%) in 2017, 66(62.9%) in 2018. All signed DNACPR form, 74(70.5%) joined EOL care program with ACP signed, 67(63.8%) signed consent for CHF. Time kept nil by mouth until commence CHF was significantly less in Geriatric wards (3.6 days) than non- Geriatric wards (6.9 days). Increased nursing buy-in participation in CHF ;59.6% (2018) vs 33.3% (2016/2017). 34 families of surviving patients were successfully contacted for phone satisfaction survey, 82.5% rated satisfaction on the program. Feeding issues are common in end of life care. Poorly handled, it leads to conflict and poor quality of care. Our interdisciplinary protocol aligns stakeholders with carers via a documented goal of care and systematic care plan. Through empowering staff, we may in turn empower and engage carers as partners in quality care for severely frail elderly.