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Lies, damned lies, and statistics
A popular newspaper recently reported statistics under the headline Kill by mouth that hunger and/or dehydration were a factor in 828 patient deaths in hospitals and care homes in 2014/2015.
The figure from the Official of National Statistics (ONS) do show that malnutrition or dehydration were associated in some way with mortality in hospitals (n = 711) and care homes (n=117). But these figures that were highlighted and reported in the press need to be better understood, with the statistical experts at ONS providing some guiding notes as to how these should be interpreted. What the figure does not mean is that 117 patients starved to death or died of thirst in care homes.
The figures include both deaths directly attributable to malnutrition and dehydration as well as more commonly as a secondary factor in their death. Malnutrition may be recorded on the death certificate as a factor contributing directly to a death when it was a complication of a different underlying cause, such as cancer of the stomach, for example.
Importantly these mortality statistics do not necessarily mean poor levels of care.
The figures don’t provide enough information to link the deaths to poor care, either in hospital or in care home settings. There are many explanations as to why someone becomes malnourished: for example they may have cancer of the digestive tract, which means they can't eat properly or can't absorb nutrients; they may have suffered a stroke or have advanced dementia which can cause difficulties chewing and swallowing; or they may abuse alcohol and so not eat properly. The deceased may have been malnourished before they went into hospital or care home, and perhaps only have been a resident for a very short time and the malnutrition may have nothing to do with not being fed properly.
So having a disease such as advanced cancer can be an underlying cause of malnutrition. But that's not to say that patients who are terminally ill should have fluid and nutrients withheld. On the contrary, guidelines make it clear that even if a patient can't eat or drink they should still be provided for. The ONS has, in fact, looked into how care is provided to patients based on how well friends and relatives think they were looked after in the last days of their life. The survey, covering England only, found that 75% agreed that support was provided by health professionals to help the patient eat, while 13% disagreed. 78% of those asked agreed that support was provided to drink while 12% disagreed.
We know things have improved, and CQC guidelines include the provision of nutritious foods to meet dietary requirements as part of care planning . But malnutrition is still an issue and it is time-consuming to ensure our vulnerable care home populations are fed properly and adequately hydrated. Let’s make sure that mortality statistics for malnutrition and dehydration are NEVER a result of poor care.
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