To PEG or Not to PEG

To PEG or not to PEG

Cervo, FA. Bryan and L. Farber, S. (2006) A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics, volume 61, number 6.

Introduction

·      Review article looking at the evidence for PEG placement for patients with advanced dementia.

·      For patients with severe dementia deciding whether to use or withhold artificial nutrition/ hydration is difficult.

·      Eating is typically the last activity of daily living to become impaired.

·      Difficulties eating are associated with the final phase of dementia.

·      Percutaneous endoscopic gastrostomy (PEG) tube placement is now a relatively simple procedure requiring local anaesthetic.

·      The American Gastroenterological Association (AGA) allows for PEG tubes when: 1. The patient cannot/ will not eat. 2. The gut is functional. 3. The patient can tolerate placement of the device.

Review of the evidence for PEG tube placement

Health domain	Evidence
Nutrition	·      Increasing weight loss and pressure ulcer development were associated with longer term tube feeding. ·      Studies have shown that nutritional markers did not significantly improve after PEG tube placement.
Skin integrity	·      Incontinent dementia patients who are tube fed are more likely to be restrained, increasing the risk of pressure ulcer formation.
Aspiration Pneumonia	·      Aspiration occurs in up to 50% of patients with feeding tubes. ·      PEG tube placement may increase the risk of GI reflux. ·      A history of previous aspiration is a poor prognostic indicator for tube feeding. ·      Aspiration of oral secretions is not prevented by insertion of a PEG tube.
Quality of life	·      Elderly patients often have an impaired thirst mechanism and may not be distressed by dehydration. ·      Dehydration decreases the production of bodily fluids such as urine and oral secretions, which reduces the need for suctioning/ toileting. ·      Patients with feeding tubes are more likely to be restrained with mittens to prevent them pulling out the tubes. This causes distress.
Functional status and survival	·      Severe dementia is a terminal illness not reversed by feeding tube placement.

The Decision Making Process

·      Advance directives – should reflect the patient’s specific wishes regarding artificial nutrition/ hydration. In there absence decisions are made based on what a surrogate believes the patient would choose if they had capacity.

·      Ethical considerations – the clinical benefit of PEG tube feeding is unclear, therefore decisions should be made based on the patients/families values and preferences.

·      Cultural background and religious beliefs should be considered.

Key Learning Outcomes

·      There is no clear evidence (randomised controlled trials) proving that PEG tube placement will improve the quality of life, or functional status of patients with advanced dementia.

·      Decisions need to be made with the patients’ family/ surrogate considering the patients cultural background, religious beliefs and personal views.