BACKGROUND: Nationwide, many nursing home (NH) residents with advanced cognitive impairment are tube fed, despite no demonstrable benefits of this intervention in this population. Studies suggest that organizational features of NHs are associated with this practice, but underlying reasons for these associations are poorly understood. METHODS: We conducted a focused ethnographic study of 2 NHs in South Carolina, 1 with a high tube-feeding rate (41.8%) in patients with advanced dementia, and 1 with a low rate (10.7%). Data were collected about physical environment, mealtime and decision-making processes, and explicit and implicit values using 80 hours of direct observation, semistructured interviews with 30 key facility personnel, and abstraction of publicly available material describing the facilities. Data were analyzed using qualitative methods. RESULTS: Striking variations in organizational culture were identified. The low-use NH had a homelike environment centered on food as an important component of daily life, mealtimes staffed with knowledgeable nursing assistants who valued hand feeding, and advance care planning that included family and palliative care options. In contrast, the high-use NH had an institutionlike environment, poorly staffed mealtimes, and staff attitudes favoring feeding tubes to avoid aspiration and to meet perceived regulatory compliance. CONCLUSIONS: The NH culture influences the approach to feeding in advanced cognitive impairment, whether by hand or placement of a feeding tube. Key features of NHs with a low rate of tube-feeding use include a physical environment that promotes the enjoyment of food, administrative support, and empowerment of staff to value hand feeding and shared decision-making processes involving family members.
BACKGROUND: Nationwide, many nursing home (NH) residents with advanced cognitive impairment are tube fed, despite no demonstrable benefits of this intervention in this population. Studies suggest that organizational features of NHs are associated with this practice, but underlying reasons for these associations are poorly understood. METHODS: We conducted a focused ethnographic study of 2 NHs in South Carolina, 1 with a high tube-feeding rate (41.8%) in patients with advanced dementia, and 1 with a low rate (10.7%). Data were collected about physical environment, mealtime and decision-making processes, and explicit and implicit values using 80 hours of direct observation, semistructured interviews with 30 key facility personnel, and abstraction of publicly available material describing the facilities. Data were analyzed using qualitative methods. RESULTS: Striking variations in organizational culture were identified. The low-use NH had a homelike environment centered on food as an important component of daily life, mealtimes staffed with knowledgeable nursing assistants who valued hand feeding, and advance care planning that included family and palliative care options. In contrast, the high-use NH had an institutionlike environment, poorly staffed mealtimes, and staff attitudes favoring feeding tubes to avoid aspiration and to meet perceived regulatory compliance. CONCLUSIONS: The NH culture influences the approach to feeding in advanced cognitive impairment, whether by hand or placement of a feeding tube. Key features of NHs with a low rate of tube-feeding use include a physical environment that promotes the enjoyment of food, administrative support, and empowerment of staff to value hand feeding and shared decision-making processes involving family members.
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