Geriatric Quick Consult PEG Tube Decisions Do #4
Ask the family members what they are hoping the PEG will do for the patient.
Below are some facts to help you guide the discussion.
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| Knowledge | Action |
|---|---|
| Survival: Mortality after PEG placement is high (22% die within a month and more than 50% within a year).
Observational studies do not suggest any survival benefit for PEG over hand feeding in patients with advanced dementia and eating problems. |
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| Nutrition: There is no evidence that adequate nutrition reverses weight loss and depletion of lean and fat body mass in patients with advanced dementia or progressive neurological disease.
Furthermore, the prescribed amount of feed is often not administered due to technical problems (tube leak, blockage or inability of family to cope with feeding regimen) or poor tolerance by the patient (gastric distention, high residuals, reflux, diarrhea). |
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| Aspiration: PEG placement cannot be expected to reduce the risk of aspirating oropharyngeal secretions and there is no data to show it reduces the risk of aspirating gastric contents.
In fact, PEG may reduce lower esophageal sphincter pressure and increase the risk of gastroesophageal reflux. Other factors that may promote aspiration of gastric contents are gastric distention, delayed gastric emptying and the difficulty of adhering to strict aspiration precautions in a demented patient (slips down in bed, needs to have diaper changed etc.). |
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| Comfort: There is no data to suggest that demented patients with eating problems are more comfortable after PEG placement.
Indeed, the nature of the placement procedure, presence of a tube in the abdominal wall, greater likelihood of restraint use, increased urine and stool production and high occurrence of PEG-related complications make it likely the patient will have more discomfort. |
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| Function: Nutritional supplementation orally, or by feeding tube, in frail nursing home residents has not been shown to improve strength or function. |
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| Quality of life: There is no standardized method of measuring QOL in advanced dementia and no objective data on QOL after PEG placement but, as mentioned above, comfort and function are not improved and the patient may have more pain if they develop complications.
Furthermore, they are usually denied the pleasure of oral food and become more socially isolated as they no longer go to the dining room to eat. |
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| Pressure sores: Tube feeding has not been shown to heal pre-existing pressure sores or prevent new ones during 6 months of follow-up.
Indeed, it is conceivable that it might aggravate the situation by increasing urine and stool production and decreasing mobility. |
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