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PEG tube decisions in persons with impaired cognitive function.

The technique of percutaneous endoscopic gastrostomy (PEG) was developed in 1980 and has become the preferred method of delivering nutrition to those who cannot eat but still have a functional gastrointestinal tract.

Mortality
  • While the PEG placement procedure itself is considered low risk (1% mortality), mortality in the 30 days following PEG placement is around 22%.
  • Fewer than half of patients survive for a year or more and very few return to living in their own homes.
Complications
  • PEG-related complications are reported in up to 70% of patients.
  • PEG-related complications lead to hospitalization or death in 3% to 11% of cases.
  • Aspiration is one of the most common problems associated with tube feeding and may be related to reflux of gastric contents or continued aspiration of saliva.
  • Aspiration pneumonia is reported in about 20% to 30% of PEG-fed patients and is a frequent terminal event 1.
Indications
PEG placement is clearly indicated when prolonged inability to eat is associated with:
  • an acute event from which recovery is anticipated e.g. trauma or surgery
  • uncomplicated dysphagia e.g. severe esophageal dysmotility
  • CVA with unimpaired consciousness
However, the benefits are not so clear in patients with dementia or other progressive neurological disease. Two recent reviews of published data on outcomes after PEG placement in advanced dementia failed to demonstrate that it prolonged life, improved nutrition, prevented aspiration, improved function, made the patient more comfortable or improved wound healing 2, 3. There is very little objective data available on quality of life (QOL) after PEG but since tube feeding is associated with increased restraint use, social isolation, increased stool and urine production and, sometimes nursing home admission to manage the feeds, the impact is likely to be negative.

Studies looking at the PEG decision-making process in older adults concluded that the decision was often made at a time of crisis, with incomplete information and no reasonable alternative to tube feeding being perceived. Furthermore, only about half of the surrogate decision-makers were confident that the patient would have wanted a PEG, a third regretted their decision to place the PEG and only a third would opt to have a PEG themselves4, 5. In counseling about PEG placement, physicians have tended to focus on the complications of the procedure itself rather than on the subsequent benefits and burdens of tube feeding. Decision-makers need to be given more information about the expected outcomes and possible negative aspects of tube feeding and to be offered alternatives such as persisting with careful spoon-feeding or referral for palliative care.


DO all of these DON'T do any of these
Meet with family yourself as soon as possible. ignore the problem until patient is ready for discharge.
Ask for help from healthcare providers familiar with the patient or from the Geriatric Consult Service. suggest a "trial" of PEG feeding.
Review advance directives. assume aspiration on modified barium swallow (MBS) is an absolute contra-indication to oral feeding.
Review likely outcomes. arrange PEG in a diabetic, or someone with symptoms of impaired gastric emptying, without ordering a gastric emptying study first.
Review possible complications and negative factors. impose your values on patients or families.
Discuss concerns about thirst and hunger.      
Respect cultural and religious differences.      
Discuss managing PEG feeding at home.      
Discuss alternatives to PEG feeding.      


References:

  1. American Gastroenterological Association Technical Review on Tube Feeding for Enteral Nutrition. Gastroenterol. 1995;108:1282-1301.
  2. Finucaine TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. A review of the evidence. JAMA. 1999;282:1365-81.
  3. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342:206-10.
  4. Callahan CM, Haag KM, Buchanan NN, Nisi R. Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 1999;47:1105-10.
  5. Mitchell SL, Berkowitz RE, Lawson FME, Lipsitz LA. A cross-national survey of tube-feeding decisions in cognitively impaired older persons. J Am Geriatr Soc. 2000;48:391-7.

References for entire PEG tube decision module, please click here.

 

 

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