Rural-urban differences in end-of-life care: the use of feeding tubes

Efforts to improve end-of-life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community-to-community variations in end-of-life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n = 78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n = 4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural-urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.