Enteral feeding in end-stage dementia: A comparison of religious, ethnic, and national differences in Canada and Israel

Background. Although enterai feeding in end-stage dementia is thought by many clinicians to he "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.