Rethinking the role of tube feeding in patients with advanced dementia

Ethical challenges in end-of-life therapies in the elderly

With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person's values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers. At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs. The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.

Advances in hospital medicine: a review of key articles from the literature

Multiple published studies in recent years have provided results and information that hospitalists can apply directly to patient care. This update summarizes some important articles published over the past 18 months. Article summaries are categorized into perioperative care, infectious disease, diagnosis of venous thromboembolism, end of life care, and guidelines for the management of patients with COPD or atrial fibrillation.

Facilitated feeding in disabled elderly

Nutrition and health are major concerns to older individuals. Whereas illness associated with overnutrition has been well characterized, poor health associated with undernutrition has received less attention. Malnutrition continues to plague the elderly in developed and underdeveloped countries alike, and is becoming of more concern as global demographic changes predict increasing proportions of elderly in all societies. Nutrition influences many chronic disease processes affecting older individuals. In addition, changes in physiology, metabolism, and function accompanying aging result in altered nutritional requirements. The enhancement and maintenance of health and function are now more possible with the new knowledge of nutritional needs in old age. Designing nutritional therapy to treat malnutrition associated with illness in older patients requires an understanding of the aging processes, a careful setting of treatment goals, and multidisciplinary collaboration.

Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding

It is the position of the American Dietetic Association that the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases. Registered dietitians have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When patients choose to forgo artificial nutrition and hydration, or when patients lack decision-making capacity, and others must decide whether or not to provide artificial nutrition and hydration, the registered dietitian has an active and responsible professional role in the ethical deliberation around that decision. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the patient and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision to administer or withhold nutrition and hydration requires ethical deliberation. The registered dietitian's understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provides an essential basis for ethical deliberation on issues of nutrition and hydration.

The use of life-sustaining treatments in hospitalized persons aged 80 and older

OBJECTIVES

To characterize the use of life-sustaining treatments in hospitalized patients aged 80 and older.

DESIGN

A prospective cohort study.

SETTING

Four teaching hospitals in the United States that participated in the Hospitalized Elderly Longitudinal Project (HELP).

PARTICIPANTS

Hospitalized patients aged 80 and older.

MEASUREMENTS

We report the rates of admissions to intensive and coronary care units and the rates of use of cardiopulmonary resuscitation (CPR), ventilators, right heart catheterization, artificial nutrition and hydration, surgical interventions, hemodialysis, and blood transfusions.

RESULTS

Of the 1,266 patients enrolled in HELP, 72 died during the enrollment hospitalization. The median age of those who died was 86 (range 83-89). Of the patients who died, the median number of activities of daily living impairments was two (range 1-4) before hospitalization, and 70% reported their baseline quality of life as fair or poor. Most patients who died had stated that they did not want aggressive care; 70% wanted their care focused on comfort rather than prolonging life, and 80% had a do-not-resuscitate order. However, the majority (63%) of the patients received one or more life-sustaining treatments before they died. Fifty-four percent were admitted to intensive or coronary care units, 43% were on a ventilator, 18% received CPR, 18% received tube feeding, 17% underwent surgery, 15% had right heart catheterization, 14% received blood transfusions, and 6% had hemodialysis. Intensive care did not affect survival time.

CONCLUSION

The use of life-sustaining treatments was prevalent in very old patients who died in the course of hospitalization, despite the fact that the majority had a preference for comfort care. This lack of congruence warrants further investigation and efforts to provide care that is more consistent with patients' preferences.

A prospective evaluation of outcome in patients referred for PEG placement

BACKGROUND

PEG feeding is not recommended for short-term use because the 30-day mortality after PEG placement is substantial. The primary aim of this study was to prospectively identify factors predictive of survival in patients referred for PEG placement.

METHODS

All patients for whom gastroenterology consultation was sought for feeding PEG placement were prospectively studied. Demographic data, Charlson comorbidity index, and functional status were recorded at entry. After PEG placement, patients were followed for up to 12 months.

RESULTS

Of the 67 patients for whom consultation was requested, 58 were eligible for the study and 50 underwent PEG placement. The 7-day and 30-day mortality rates in the PEG placement group were 4% and 20%, respectively. In multivariate analysis, only the Charlson index > or =4 was associated with decreased survival time (relative hazard = 2.9: 95% CI [1.20, 7.21], p = 0.019). Median survival in patients with Charlson comorbidity index > or =4 was significantly shorter than that in patients with Charlson index < 4 (p = 0.013).

CONCLUSIONS

A Charlson comorbidity index > or =4 was significantly associated with shorter patient survival after initial consultation. Careful consideration of predictive factors of survival may improve patient selection for feeding PEG placement.

Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term enteral access

This paper is based on the opening lecture of the 23rd Congress of the European Society of Parenteral and Enteral Nutrition (ESPEN), given on September 9, 200l in Muenchen, Germany. The article relates the story of the origin and the evolution of the percutaneous endoscopic gastrostomy or PEG, based on the then-novel concept of sutureless approximation of a hollow viscus to the abdominal wall. It also provides a perspective of the clinical applications of PEG, in general, and the author's pediatric experience in particular. Additionally, it briefly describes the old and new expanded applications of the PEG concept. In this communication, the author of the procedure encourages young investigators to ask relevant questions in research and in clinical settings aimed at developing new ideas and concepts in the field of nutrition. He also stresses the need to carefully reflect upon the ethical and moral implications of new discoveries. The article contains pertinent illustrations and bibliographic references.

The effect of nutritional intervention in elderly subjects residing in group-living for the demented

OBJECTIVES

We studied the nutritional status and the effects of nutritional intervention on body weight, cognition and activities of daily life (ADL)-function in demented individuals.

DESIGN

Controlled non-randomised study.

SETTING

Group-living for demented elderly (GLD), ie community assisted housing.

SUBJECTS AND INTERVENTIONS

Twenty-two residents living in one of two units (GLD-I), received oral liquid supplements (1720 kJ/410 kcal/day) and the personnel of the GLD-I were given nutritional education. Fourteen residents in the other unit (GLD-C) served as controls. After 6 months 21 (83 (4) y, 81% women) and 12 (85 (4) y, 100% women) of the participants, respectively, were re-examined according to body mass index (BMI, kg/m2), cognitive function (Mini Mental State Examination (MMSE, 0-30 p) and Clinical Dementia Rating Scale (CDR) and the Katz' ADL index.

RESULTS

Body mass index (BMI) < or =20 was found in 19% of the participants and 44% had BMI< or =23. BMI correlated with MMSE (r=0.43, P<0.01). The weight of the residents in the intervention group increased by 3.4 (3) kg (P=0.001) at follow-up, whereas the weight remained unchanged in the control group. The cognitive function was low at the start in both groups, ie MMSE approximately 9 and no apparent positive effect of the nutritional intervention was seen. In addition, the ADL functions appeared to deteriorate in both groups.

CONCLUSIONS

Being underweight was common among demented elderly in group-living and was related to low cognitive capacity. Five months of oral supplementation, along with education of personnel, was followed by a weight gain. In this study the nutritional treatment did not affect the rate of decline in cognitive function or Katz' ADL index.

SPONSORSHIP

Supported by grants from the Swedish National Board of Health and Social Welfare. Semper Foods AB provided the liquid supplements.

Refusing artificial nutrition and hydration: does statutory law send the wrong message?

Ethical consensus and appellate court decisions view artificial nutrition and hydration (ANH) as medical treatment that can be refused like other treatments. However, advance directive statutes may produce obstacles for refusal of ANH, as distinct from other life-sustaining treatments, in patients who lack capacity. This paper reviews state statutes and appellate case law regarding medical decision making for patients who lack decisional capacity. Twenty states (39%) have one or more explicit statutory provisions delineating a separate and more stringent standard for ANH refusal. These standards include higher evidentiary standard; requirement for specific preauthorization, qualifying medical conditions, second medical opinion, or judicial review; refusal not permitted; refusal not permitted if death would result from "starvation" or "dehydration"; and previous law with higher standard applies to old documents. In 11 of these states and in eight others, statutory law contains language that could be misinterpreted, implying, but not rising to, an explicitly higher standard. Four appellate decisions departed from the judicial consensus that ANH can be refused like other treatments, but subsequent court decisions or legislative enactments reduced or eliminated their impact. Legislators and the courts should ask whether higher standards for ANH refusal are appropriate in light of case law authority that ANH should not be treated differently and in light of statutory language that preserves those common law rights. These higher standards may make it more difficult in certain states to refuse ANH for patients who lack capacity or place a burden on good practice by making providers fearful of the law.

Are we using percutaneous endoscopic gastrostomy appropriately in the elderly?

Many percutaneous endoscopic gastrostomy patients are very elderly and frail. Outcomes after percutaneous endoscopic gastrostomy have been disappointing in some instances: about a fifth of patients are dead within 30 days of the procedure and those that survive often have a severely impaired functional status. Many healthy elderly persons would not wish for tube feeding especially in the context of advanced dementia. Despite this the number of patients receiving percutaneous endoscopic gastrostomy continues to increase. The case mix, outcomes and ethical issues of percutaneous endoscopic gastrostomy feeding are reviewed. Guidance on selection of appropriate patients is given.

Institutional feeding of the elderly

Not only is there a high prevalence of malnutrition among the elderly admitted to hospital and other institutions, but nutritional status seems to decline during admission, not only as a result of disease but also problems with catering and feeding policies, which are not well-geared to the needs of the sick. This results in high food wastage rates and inadequate macro- and micronutrient intakes to meet requirements. In the elderly, decreased portion size and increased energy, protein and micronutrient density have been shown to be effective in decreasing wastage and improving intake. Other strategies for improving intake are reviewed, including a better environment, a reduction in drugs causing anorexia, help with eating, and less interruption of meals by procedures and ward rounds. Targets for nutritional intake and aims of feeding are reviewed.

Rural-Urban Differences in End-of-life Care: The Use of Feeding Tubes

Efforts to improve end-of-life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community-to-community variations in end-of-life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n = 78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n = 4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural-urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people

OBJECTIVE

To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube.

DESIGN

A prospective, multicenter cohort study.

SETTING

Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel.

PARTICIPANTS

122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded.

MEASUREMENTS

We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months.

RESULTS

Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups.

CONCLUSION

In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.

Healthcare costs associated with percutaneous endoscopic gastrostomy among older adults in a defined community

OBJECTIVES

The effectiveness of percutaneous endoscopic gastrostomy (PEG) in older adults remains controversial. Although prior studies have examined the safety of PEG and its impact on nutrition, there are limited data on the economic costs. The purpose of this study is to describe the healthcare costs associated with PEG tube feeding over 1 year.

DESIGN

Prospective cohort study.

SETTING

Small community of approximately 60,000 residents served by two hospital systems.

PARTICIPANTS

One hundred five (70%) of 150 patients age 60 and older receiving PEG over a 24-month period in the targeted community who permitted access to their medical records.

MEASUREMENTS

Patients were interviewed at baseline and every 2 months for 1 year to obtain information on use of enteral formula, complication rates, and health services use. We obtained inpatient charge data for all hospitalizations and PEG procedures for 1 year.

RESULTS

Censoring patients at death or 1 year post-PEG, the mean number of days of PEG tube feeding was 180 (range 5-365). The average cost for PEG tube feeding for this cohort of patients was $7,488 (median $3,691) in 1997 and 1998. The average daily cost of PEG tube feeding was $87.21 (median $33.50). The estimated cost of providing 1 year of feeding via PEG is $31,832 (median $12,227). The main components of this cost include the initial PEG procedure (29.4%), enteral formula (24.9%), and hospital charges for major complications (33.4%).

CONCLUSIONS

Direct charges associated with PEG tube feeding over 1 year are conservatively estimated at $31,832; there was considerable variation in charges because of the cost of rare but costly major complications. Also, feeding patients via PEG resulted in cost shifts in terms of the primary payor. The economic cost of PEG tube feeding is another consideration in decision making for long-term enteral feeding among older adults.

Dementia

Alzheimer's disease is the most common cause of dementia, but often several other conditions causing dementia are present on brain autopsies. Palliative care medical issues are similar in all late stage progressive degenerative dementias and include; cardiopulmonary resuscitation, transfer to acute care setting, antibiotic therapy, and tube feeding. Behavioral symptoms of dementia include agitation and resistiveness to care. Quality of life of individuals suffering from dementia is enhanced by availability of meaningful activities and by avoidance of restraints. Family support and involvement are crucial for optimal care. Formulation of advanced directives or an advance proxy plan is important for assuring the patient's previous wishes or best interests are considered when decisions about treatment strategies are made.

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.

Nutrition in gastroenterology and hepatology

Nutritional issues, sometimes obvious and sometimes not so obvious, confront the primary care practitioner on a daily basis. Understanding the multi-disciplinary nature of nutrition science and clinical nutrition and having a basic understanding of gastrointestinal tract digestive and absorptive physiology can only help sort out the many issues involved. The general practitioner needs a core understanding of the principles of nutrition assessment.

A survey on percutaneous endoscopically placed gastrostomy in the Northwest: influence of work setting

OBJECTIVE

A survey was undertaken to determine the influence of practice setting on the way Pacific Northwest gastroenterologists perform and manage percutaneous endoscopically placed gastrostomy (PEG).

METHODS

A 12-question survey was distributed to 196 members of the Pacific Northwest Gastroenterology Society (PNWGS) regarding their specifics of placing and managing PEG. The responses were compared according to work setting, i.e., private practice, armed services, staff model HMO's, and university affiliated hospitals. The data were analyzed using the chi2 test.

RESULTS

Sixty-nine of 126 practicing gastroenterologists responded; 75% were in private practice (PP) and 25% in the combined other work settings (non-PP). The mean number of PEG placed by all groups was 23. Seventy-three percent of PP performed PEG without a second physician. Antibiotics were used prophylactically in both PP and non-PP by 96%. There was no difference between groups in use of standardized forms or in time before instituting feedings. The non-PP groups used preprocedure labs (p = 0.037) and loosening skin surface bumpers (p = 0.035) more frequently. The uniform impression was that PEG was associated with the same or fewer complications currently than in the past.

CONCLUSIONS

In the PP setting, gastroenterologists tend to place PEGs without a second physician and use standardized forms and bumper loosening less frequently than non-PP gastroenterologists. These variations reflect that teaching institutions as well as staff model HMOs make access to an assistant easier. Respondents expressed confusions on billing for PEG. They perceived the procedure to be as safe or safer than in the past. The PEG has evolved into a frequently performed procedure whose practice variations are outgrowths of one's work environment as well as one's training.

Treatment of protein-energy malnutrition in chronic nonmalignant disorders

Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, the causal connections between malnutrition and a poorer prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of patients with wasting disorders. We reviewed studies of the treatment of PEM in cases of chronic obstructive pulmonary disease, chronic heart failure, stroke, dementia, rehabilitation after hip fracture, chronic renal failure, rheumatoid arthritis, and multiple disorders in the elderly. Several methodologic problems are associated with nutrition treatment studies in chronically ill patients. These problems include no generally accepted definition of PEM, uncertain patient compliance with supplementation, and a wide range of outcome variables. Avail-able treatment studies indicate that dietary supplements, either alone or in combination with hormonal treatment, may have positive effects when given to patients with manifest PEM or to patients at risk of developing PEM. In chronic obstructive pulmonary disease, nutritional treatment may improve respiratory function. Nutritional therapy of elderly women after hip fractures may speed up the rehabilitation process. When administered to elderly patients with multiple disorders, diet therapy may improve functional capacity. The data regarding nutritional treatment of the conditions mentioned above is still inconclusive. There is still a great need for randomized controlled long-term studies of the effects of defined nutritional intervention programs in chronically ill and frail elderly with a focus on determining clinically relevant outcomes.

Ethical and legal issues in palliative care

As palliative care emerges as a respected and important component of contemporary health care, ethical issues will arise that confront and contest the provision of medical care. The basic principles of medical ethics, embodied in beneficence, nonmaleficence, autonomy, and justice, guide primary care physicians in dealing with dying patients. This article will discuss the basic ethical principles and the principle of double effect, decision-making capacity, advance directives, withholding and withdrawing life-sustaining therapy, futility, artificial nutrition and hydration, do-not-resuscitate orders, and physician-assisted suicide and euthanasia.

Care of patients with alzheimer's disease and their families

Although the medical management options in Alzheimer's disease are limited, physicians have a central role in addressing multiple associated care needs of these patients and their families. These needs change according to different stages of the disease. Sensitive disclosure of diagnosis and providing education, guidance, and appropriate referrals to community resources are essential components to an effective care plan. By making use of a multidisciplinary network of care providers, the physician can ensure the family of proactive management throughout the course of the disease.

A decision aid for long-term tube feeding in cognitively impaired older persons

OBJECTIVE

To describe the development and evaluation of a decision aid for long-term tube feeding in cognitively impaired older people.

DESIGN

Before-and-after study.

SETTING

Acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Substitute decision makers for 15 cognitively impaired inpatients 65 years and older being considered for placement of a percutaneous endoscopic gastrostomy tube.

MEASUREMENTS

Questionnaires were used to compare the substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to the decision aid. The acceptability of the decision aid was also assessed.

RESULTS

Substitute decision makers significantly increased their knowledge (P = .004) and decreased their decisional conflict (P = .004) regarding long-term tube feeding after using the decision aid. The impact of the decision aid on predisposition toward the intervention was greatest for those who were unsure of their preferences at baseline. All substitute decision makers found the decision aid helpful and acceptable despite very difficult and emotional circumstances.

CONCLUSIONS

A decision aid improves the decision-making process for long-term tube feeding in cognitively impaired older patients by decreasing decisional conflict and by promoting decisions that are informed and consistent with personal values. There are particular challenges for developing and evaluating these tools in the context of end-of-life decisions.

Surrogate decision makers' attitudes towards tube feeding in the nursing home

In the nursing home, a widely accepted medical practice is to recommend the initiation of long term tube feeding in residents with eating difficulties. However, frequently the nursing home resident has dementia, lacks decision-making capacity, and has no advance directives to guide the physician and the family member(s). Therefore, the family member or another surrogate decision maker has to make the difficult decision of whether or not to consent to the placement of a feeding tube. We surveyed 50 English speaking surrogates of nursing home residents who were on a feeding tube for at least 6 months. Each surrogate was contacted by telephone and was administered a 16-item structured questionnaire. Statistical analyses included frequency distributions, and the Wilcoxon signed rank test for two related samples. Most surrogates rated the residents' quality of life as poor or extremely poor. Yet, 78% of the surrogates perceived tube feeding to be beneficial, 62% would repeat their initial decision to initiate tube feeding, and 68% would not consider removal of the feeding tube. Their leading concerns were medical complications, tube feeding's impact on each resident's quality of life, and adequacy of nursing care. The surrogates were satisfied with their initial decision for the placement of a feeding tube despite their perception that there was no improvement in the quality of life of the residents. The surrogates may have viewed tube feeding as a life prolonging measure.

Fatal retroperitoneal haemorrhage: an unusual complication of percutaneous endoscopic gastrostomy

A 93-year-old lady with dementia, neurological dysphagia and aspiration pneumonia, died from massive retroperitoneal haemorrhage which developed as a rare and, it is believed, hitherto unreported, complication of percutaneous endoscopic gastrostomy (PEG), which was performed for feeding purposes. It is postulated that the initial, unsuccessful attempt at needle puncture of the stomach, under endoscopic guidance, had resulted in iatrogenic perforation and laceration of the splenic and superior mesenteric veins close to their confluence with the portal vein. It would also appear that dense fibrous adhesions between the pyloro-antral region of the stomach and the posterior hepatic surface had altered the immediate anatomical relations of the stomach in such a manner as to have predisposed to these events.

Percutaneous endoscopic gastrostomy-20 years later: a historical perspective

BACKGROUND/PURPOSE

Percutaneous endoscopic gastrostomy (PEG), initially developed for children with inability to swallow, had its first presentation at the annual meeting of the American Pediatric Surgical Association in Florida in 1980. Based on the novel concept of the sutureless approximation of a hollow viscus to the abdominal wall, this minimally invasive procedure has become the standard for direct gastric access worldwide. This report is a brief retrospective about the evolution of PEG and the expanded applications of the surgical concept on which it is based.

METHODS

Information related to PEG was obtained from personal records, a focused literature search, and data from various registries and the industry.

RESULTS

The search identified 836 peer-reviewed publications directly related to PEG. The original Journal of Pediatric Surgery article has received 483 bibliographic citations. The procedure has had a profound impact on nutritional management, particularly among adult patients. Over 216,000 PEGs are performed annually in the United States. Twelve major manufacturers produce PEG or PEG-related enteral access devices. Select expanded applications of PEG and its principle include indications beyond feeding, use in high-risk patients, percutaneous jejunostomy, percutaneous cecostomy, correction of gastrostomy leakage and gastric volvulus, multiple PEG portals for intragastric interventions, and laparoscopically assisted gastrostomies.

CONCLUSIONS

Over 20 years, percutaneous endoscopic gastrostomy has experienced exponential growth. Improved guidelines and technical refinements have added to its safety. The concept on which it is based has created a ripple effect and led to numerous applications beyond gastric access for feeding. In an era when so many of our procedures are adopted from "adult" general surgery, it is worthwhile to have an historical perspective on PEG, a technique that originated in pediatric surgery.

Tube feeding in nursing home residents with severe and irreversible cognitive impairment

OBJECTIVES

This study was undertaken to determine the degree to which selected demographic and clinical variables are associated with the use of feeding tubes in older nursing home residents with very severe and irreversible cognitive impairment.

DESIGN

Descriptive, cross-sectional, population-based study.

SETTING

Kansas nursing homes from January 1, 1994, through June 30, 1998.

PARTICIPANTS

A total of 4,997 nursing home residents with very severe and irreversible cognitive impairment comprised the study population. Subjects were identified using data in Minimum Data Set (MDS) reports. Those who were included in the study population were over the age of 65, had two consecutive Cognitive Performance Scale scores of 6, were without evidence of significant subsequent improvement, and were not comatose.

MEASUREMENTS

The MDS data on each resident were examined to determine subjects' age, ethnicity, gender, Medicaid eligibility, disease diagnoses, physical functioning, and oral/nutritional status, including feeding tube status. The MDS was also used to determine urban versus rural location of the nursing home. The association between the use of feeding tubes and selected demographic and clinical characteristics was then examined using bivariate and logistic regression tests.

RESULTS

Of the 4,997 residents in the study population, 577 (11.6%) had feeding tubes. In multivariate analysis, feeding tube use was found to be associated with swallowing problems (odds ratio (OR) 5.4, 95% confidence interval (CI) 4.3-6.8); urban location of nursing home (OR 2.9, 95% CI 2.3-3.5); non-white race (OR 2.7, 95% CI 1.9-3.6); stroke (OR 2.5, 95% CI 2.0-3.1); and absence of dementia (OR 2.5, 95% CI 2.0-3.1). Feeding tubes were also more weakly associated with age <86 years, male gender, dependency for all activities of daily living, and absence of a living will. Feeding tube use was not found to be associated with chewing problems, Medicaid status, or resuscitation status.

CONCLUSIONS

Clinical variables including swallowing problems, stroke, and absence of dementia were strongly associated with the use of feeding tubes in this cross-sectional, population-based study. In addition, urban location of nursing home and non-white race were significantly associated with feeding tubes. These findings suggest that feeding tube decisions are strongly influenced by nonclinical factors and invite further investigation.

Interventional procedures

During the past year, numerous articles were published on interventional procedures of the stomach, focusing on upper gastrointestinal tract bleeding, gastric cancer, gastric outlet obstruction, and benign disease. In the area of upper gastrointestinal tract bleeding, early endoscopy is warranted for early therapeutic intervention and for triage. In patients with bleeding related to peptic ulcer disease, combination therapy (epinephrine injection in conjunction with electrocoagulation therapy) remains the standard of care. Hemoclipping is a new technique that may be helpful in cases in which conventional therapy fails. Repeat endoscopy should always be considered in patients in whom the first attempt at endoscopic therapy fails. In patients with bleeding related to portal hypertension, prophylactic antibiotics may decrease the risk of infections. Banding remains the therapy of choice for this group of patients. There is no documented benefit for combination therapy (banding and sclerotherapy). Transjugular intrahepatic portosystemic shunts may be helpful in the treatment of hypertensive portal gastropathy but not gastric vascular ectasias. In the area of gastric cancer, management revolves around staging. This can be accomplished best through the use of CT scan and endoscopic ultrasound. In patients with early limited disease, attempt at endoscopic mucosal resection should be considered. This technique can be performed in a variety of ways: the most common method seems to be through the use of a saline injection, to separate the mucosa-submucosal layer, followed by a cap-assisted snare resection with suction. The safety, efficacy, and outcome of this technique are reviewed. Gastric outlet obstruction remains a difficult problem to treat endoscopically. However, there is some evidence that endoscopic therapy may be successful in benign disease and should be considered prior to surgical intervention.

Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health-related quality of life among older adults receiving PEG.

DESIGN

A prospective cohort study.

SETTING

A small community of approximately 60,000 residents served by two hospital systems.

PARTICIPANTS

One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community.

MEASUREMENTS

Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics, process of care data, physical and cognitive function, subjective health status, nutritional status, complications, and mortality.

RESULTS

Over a 14-month period, 150 patients received PEG tubes in the targeted community; the mean age was 78.9. The most frequent indications for the PEG were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%). All measures of functional status, cognitive status, severity of illness, comorbidity, and quality of life demonstrated profound and life-threatening impairment; 30-day mortality was 22% and 1-year mortality was 50%. Among patients surviving 60 days or more, at least 70% had no significant improvement in functional, nutritional, or subjective health status. Serious complications were rare, but most patients experienced symptomatic problems that they attributed to the enteral tube feeding.

CONCLUSIONS

PEG tube feeding in severely and chronically ill older adults can be accomplished safely. However, there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional, nutritional, or subjective health status in this cohort of older adults. The issues raised in this descriptive study provide impetus for a randomized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating.