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Enteral Feeding in End-Stage Dementia: A Comparison of Religious, Ethnic, and National Differences in Canada and Israel

¹ Department of Geriatrics, Soroka Hospital, Ben Gurion University of the Negev, Beer-sheva, Israel.
² Division of Geriatric Medicine, Sir Mortimer B. Davis–Jewish General Hospital, McGill University, Montreal, Canada.
³ Maimonides Hospital Geriatric Centre, McGill University, Montreal, Canada.
⁴ Shoham Geriatric Centre, Pardes Hanna, Israel.
⁵ Sarah Herzog Memorial Hospital, Jerusalem, Israel.
⁶ Sunnybrook and Women's College Health Science Centre, University of Toronto, Canada.
⁷ Baycrest Centre for Geriatric Care, University of Toronto, Canada.

Address correspondence to A. Mark Clarfield, MD, FRCPC, Department of Geriatrics, Soroka Hospital, PO Box 181, Beersheva 84101, Israel. E-mail: markclar{at}bgu.ac.il

Abstract

Background. Although enteral feeding in end-stage dementia is thought by many clinicians to be "futile," it is still widely used. We examined rates of tube feeding (gastrostomy or nasogastric) in end-stage dementia in hospitals in both Canada and Israel, and hypothesized that Canadian non-Jewish affiliated hospitals would have the lowest (and Israeli institutions the highest), with Canadian Jewish hospitals exhibiting intermediate rates.

Methods. We conducted a cross-sectional survey of six geriatric long-term hospitals: two in Israel and four in Canada (two Jewish affiliated, two not; two in Ontario, two in Quebec province). Patients with end-stage dementia were assessed and further analyzed for type of feeding.

Results. In the six hospitals, 2287 long-term beds were surveyed, of which 1358 (59.4%) were used by demented patients of whom 376 (27.7%) were severely demented (Global Deterioration Scale-level 7). Of these, 24.5% (92) were fed by nasogastric tube or gastrostomy tube. Significant differences in tube-feeding prevalence were found between Canada (11%) and Israel (52.9%), with only 4.7% seen in non-Jewish Canadian institutions. Jewish affiliated hospitals in Canada exhibited an intermediate rate of 19.6%. However, for within-country dyads, wide differences were also found. When we examined patient religion, we found that Canadian non-Jewish patients had the lowest rates (3.2%), Israeli Jewish patients the highest (51.7%), and Canadian Jewish patients exhibited an intermediate rate (19.0%) of tube use.

Conclusions. Despite reservations concerning its utility, feeding tube use is reasonably widespread in patients who have reached the stage of severe dementia. Canadian institutions exhibited a lower prevalence of feeding tube use than did Israeli hospitals. Between-country and between-province differences in practice may be explained by some combination of administrative and/or financial incentives, religion, and culture; within-country and within-ethnic group differences may be caused, at least in part, by differing institutional cultures.

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