Ethical Guidelines for PEG insertion
Discuss the indications of PEG insertion?
PEG feeding should be considered for any patient who is unable to meet his/her nutritional requirements via the oral route and who is likely to require artificial nutritional support for at least four weeks.
- Clinical situations in which these conditions may apply can be divided into the following broad categories:
- Mechanical dysphagia due to obstruction to the upper aero-digestive tract (e.g. head and neck cancers).
- Neurological dysphagia- acute strokes, reversible coma, brain injury etc where swallowing may recover.
- Increased nutritional demands- malabsorption
- PEG may be indicated in carefully selected patients with:
- Progressive neurological disease with no prospect of recovery like MND. In view of the uncertainty of medical prognosis, a trial of PEG feeding may be appropriate to allow time for further assessment. This should be undertaken for a predetermined period with prearranged review.
- PEG should be avoided where there is refusal to eat because of a psychiatric disorder (e.g. depression or anorexia nervosa). Such patients are often manipulative and PEG placement is best avoided as it simply shifts the focus of attention from food to issues concerning PEG function.
- PEG and dementia
- PEG does not lead to prolongation of life or increased comfort in patients with severe dementia. So PEG is usually not indicated. A PEG may occasionally be considered
- to achieve objectives like healing pressure sores that is worsening quality of life.
- Where the dementia itself is not the primary cause of eating difficulty (e.g. the patient with dementia who has had a stroke).
L. John Hoffer forcefully argues that severely demented patients fail to benefit from tube feeding for two main reasons: they lack the potential for physical or neurological rehabilitation and they are not starving. In advanced dementia, a constant body weight, even if subnormal, rules out progressive starvation and eliminates any medical indication for tube feeding. These patients live in a condition of metabolic homeostasis characterised by a low metabolic rate, low energy (food) consumption and constant body weight without apparent detriment.
He further argues that the moral argument that it is wrong to deny a person ordinary nutrition sustenance does not apply to the severely demented person who merely indicates a disinclination to eat much food and whose weight remains nearly constant. However, on the contrary, a patient who shows a strong desire to eat but cannot be allowed to eat by mouth for mechanical or safety reasons is a candidate for tube feeding.
Further a patient who continues to loose weight despite optimisation of diet but whose BMI remains > 18.5 is more likely to be harmed than helped by tube feeding.
Discuss the ethical controversy in PEG tube feeding?
PEG feeding is contentious in patients who are terminally ill or have little potential for rehabilitation. Most retrospective studies showed no benefit of PEG placement in dementia. However, there are other uses (gastric venting, medication delivery and hydration) of a PEG tube besides feeding. These uses of PEG should also be considered in decision making as to whether a patient would benefit from PEG placement.
So PEG could be considered in advanced dementia or persistent vegetative state as long as the family understands the use of PEG (hydration and medication). They should understand that PEG will NOT improve outcome, prolong life or reverse the underlying disease state.
It is also reasonable not to place a PEG, if the patient or family so requests.
Does tube feeding prevent aspiration pneumonia in patients with dementia?
Aspiration pneumonia is often an imprecise diagnosis both conceptually and clinically. Some authors use it to refer to a self limited pneumonitis (tachypnea, wheezing and hypoxia).
The term is also used to describe pulmonary infection due to aspiration of oropharyngeal secretions into the airway. Infection probably results when normally non pathogenic organisms arrive in high enough inoculum to overcome host defences. Tube feeding cannot be expected to prevent aspiration of oral secretions, and no data show that it can reduce the risk from regurgitated gastric contents.
Finucane et al (Finucane T et al. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999; 282:1365-1380.) concluded in their pivotal paper that tube feedings did not reduce the risk of oral secretion or regurgitated gastric content aspiration. They noted that in a nonrandomized, prospective study, patients with oropharyngeal dysphagia fed orally had significantly fewer aspiration events than those fed by a tube.
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