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
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While the PEG placement procedure itself is considered low risk (1% mortality), mortality
in the 30 days following PEG placement is around 22%.
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Fewer than half of patients survive for a year or more and very few return to living in
their own homes.
Complications
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PEG-related complications are reported in up to 70% of patients.
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PEG-related complications lead to hospitalization or death in 3% to 11% of cases.
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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.
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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.
References:
- American Gastroenterological Association Technical Review on Tube Feeding for Enteral Nutrition. Gastroenterol. 1995;108:1282-1301.
- Finucaine TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia. A review of the evidence. JAMA. 1999;282:1365-81.
- Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342:206-10.
- 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.
- 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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