By JUDITH VANDEWATER

Nourishment is so much more than the intake of sufficient calories to sustain life. Food awakens the senses. A meal shared is an opportunity for companionship, amusement and intellectual stimulation.

A program begun last year at Schervier Nursing Care Center is ensuring that residents who can no longer feed themselves are not deprived of the social benefits of mealtime. Staff and volunteers hand feed residents with advanced dementia or severe motility loss who would otherwise require tube feeding.

The act of feeding is only one part of the program known as SPOON, an acronym for Seniors Partaking of Oral Nourishment. The program also is intended to help staff and residents' family members accept advanced dementia as a terminal illness, an acknowledgement that Paulette Sansone hopes will shift the emphasis from intrusive and escalating medical intervention to care that contributes first and foremost to a resident's comfort and quality of life.

Sansone is vice president of research and education for the Riverdale, N.Y.-based Schervier Center for Research in Geriatric Care, part of Bon Secours New York Health System. Together with Nadine Baker, the system's director of public relations and marketing, she will discuss the philosophical underpinnings of the SPOON program and its practical execution during a breakout session at the Catholic Health Assembly, June 22-24 in San Diego. Both women volunteer several hours a week feeding residents in Schervier's dining rooms.

Sansone said it is not uncommon in the nursing home industry for residents on tube feeding to remain in their rooms or in wheelchairs parked in corridors during mealtimes. Residents in Schervier's assisted feeding program eat in the dining room alongside other residents - a fact that their companions may point out to them as a cue that it is time to eat. Many of the residents requiring hand feeding can no longer speak and may not understand much, but their feeders try to verbally engage them, placing a soothing hand on an arm or cheek, and, in some cases, patiently coaxing them to open their lips or swallow.

The 364-bed Schervier nursing home has 73 residents on its specialized dementia floor, 20 of whom are being fed by SPOON volunteers. Volunteers also feed 25 residents on other long-term care floors. Not all residents who can't feed themselves have dementia.

Willing hands
Schervier has enlisted staff, the family members of residents and community volunteers from the Riverdale neighborhood to help with the slow process of hand feeding. About 60 volunteers have completed a training program taught by the facility's speech therapist. The volunteers learn the physiology of swallowing and the problems that residents with advanced dementia can have recognizing utensils or even remembering to open their mouths to accept food. The volunteers feed each other during training to experience what it feels like to be fed by another adult and to learn proper techniques.

Grace Bova, director of the Interfaith Caregivers volunteer program at the nursing home, has been a SPOON volunteer from the outset. She fed residents every day during her lunch hour until a few months ago when she was hit by a car. In an interview from her Riverdale home where she is recuperating, Bova called the experience of helping another person eat inspirational and rewarding.

Bova said she made it a point to arrive on time for her lunch assignment so her companion that day would not have to wait for attention. "You make them know that they count," she said. "It is important to carry on a conversation, to touch people, that helps people relax," she said. Aides have told her that the residents in the program get a sense of well-being that carries into their day.

Sansone said SPOON fulfils the Catholic imperative to respect the dignity of the individual and the sacredness of human life.

Scientifically sound approach

The impetus for the hand feeding program came from an extensive literature search that Sansone and her colleagues did last year in preparation for a major conference on dementia as a terminal illness that was hosted by Bon Secours New York. "We realized a feeding tube is futile treatment for people with advanced dementia," Sansone said. In particular, a study published in the Feb. 10, 1997, issue of the Archives of Internal Medicine found that when compared with patients who were fed by hand, advanced dementia patients who were tube fed did not live longer, or better.

Sansone said that research has debunked the widely-held belief that tube feeding reduces the risk of pressure ulcers. In fact, the increased fecal and urinary incontinence associated with feeding tubes can cause skin breakdown. Nursing home residents receiving passive artificial nutrition may be at risk of infection around the surgical site where the tube is inserted. Further, since the tubes can cause discomfort, dementia patients may get agitated and try to dislodge them. Those patients are more likely to be restrained or medicated, Sansone said.

"We thought it was time for a new standard of care," Sansone said.

Ron Hamel, a medical ethicist and CHA's senior director of ethics, said facilities typically use tube feeding because the procedure requires less staff time than hand feeding. Tube feeding carries significant collateral cost, though, in that it can foster an impersonal relationship between staff and vulnerable patients. "I'd be willing to bet hand feeding changes that dynamic," he said.

Sr. Patricia Talone, RSM, a medical ethicist who is CHA's vice president of mission services, said that hand feeding runs counter to the prevailing tendency in the U.S. to "medicalize" the dying process.

"There is a symbolism, an intimacy to feeding," Sr. Talone said. "All of us come into this world unable to feed ourselves; some of us go out that way. When you feed another person, it can create a bond. The act is a faith-based gift of companionship for the dying."