Articles: Medical Topics
PEG tubes—not a panacea
(print
version [pdf])
 What
can you learn from The American Medical Directors Association’s
annual conference in March 2006? Plenty, it turns out. This article
will hit highlights of what I discovered about percutaneous gastrostomy
(PEG) tubes while attending the conference. (Along with two physicians
and two attorneys, I presented a program on nursing
home documentation that was attended by about 500 physicians.)
Contact our office
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and other demonstrative
evidence.
Although feeding
nursing home residents through PEG tubes is common, medical evidence
questions whether it prolongs life or reduces the risk of aspiration.
Indications for PEG tube insertion include head and neck cancers,
acute stroke with persistent swallowing difficulty for one month
after hospital discharge, neuromuscular dystrophy (weakness) syndromes,
and gastric decompression (such as occurs when bowel cancer causes
obstruction). Gathering evidence shows that this popular method
of providing artificial feeding is associated with a significant
risk of complications. Placement of PEG tubes requires an invasive
surgical procedure. While the operative procedure is usually safe,
there are serious complications. Some of these include migration
of the tube out of the stomach, necrotizing fasciitis (“flesh
eating disease”), fluid overload, aspiration pneumonia,
peritonitis, abdominal abscess, bowel obstructions, gastric perforation,
GI bleeding, and restraint use. Less severe but still uncomfortable
symptoms include pain at the tube site, tube malfunction, stenosis
of the opening, local bleeding, skin excoriation, wound dehiscence,
cellulitis, gastroesophageal reflux, diarrhea, and nausea. Residents
lose social interaction and dignity.
In 1999, 34%
of severely cognitively impaired residents of United States nursing
homes had PEGs. [1] Yet there is no evidence that tube feeding
residents with advanced dementia prolongs survival, prevents aspiration
pneumonia, reduces the risk of pressure sores or infections, improves
function or provides comfort. Use of a feeding tube in a demented
patient is associated with significant increases in restraint
use, utilization of the emergency department, and hospitalization.
Residents
who develop swallowing disorders after a stroke are often considered
candidates for a PEG tube. In one study, 8 months after PEG placement,
45% of the patients had died, 25% lived and had the PEG removed,
and 30% lived with a permanent PEG. [2] However, only about 20%
of patients have dysphagia after stroke, and it resolves within
one month 80% of the time. If the physician waits for a month
and provides short term feeding with a NG tube, the majority of
PEG tube insertions might be unnecessary. A new device, the nasal
loop, is useful for avoiding unnecessary insertions of PEG tubes.
Nutrition is delivered through a nasogastric tube that is looped
into both nostrils. Short term delivery of tube feeding solution
through a nasogastric tube permits stroke patients sustains life
while allowing time to recover normal swallowing ability.
Insertion
of PEG tubes is commonly advised to reduce the risk of aspiration
pneumonia (caused by vomiting and inhaling stomach contents).
Yet there is no data to show that feeding tubes really do decrease
the risk of aspiration pneumonia. Patients with neurogenic dysphagia
fed with PEG and nasogastric tubes had similar rates of aspiration
pneumonia. Tubes placed in the jejunum did not provide a reduced
risk of aspiration either.
What drives
the pressure to insert PEGs? A complex series of emotional, institutional
and financial factors affect the provision of artificial nutrition.
Families are usually reluctant to withhold or withdraw nutrition
from loved ones. Physicians often find it easier to recommend
or perform a non-beneficial procedure than to confront difficult
and time-consuming end-of-life issues. Saying yes to family request
for insertion of a PEG tube avoids an emotional discussion of
the resident’s poor prognosis and the appropriate goals
of care. Nursing homes may require PEG placement for admission
to the facility due to staffing, regulatory, or legal concerns.
Nurses and speech therapists may promote PEG insertions in this
setting. PEG placement may be a valued source of physician income
and referrals. Hospitals may encourage PEG placements to generate
revenue (though data suggest they actually lose money on inpatient
insertions.) It costs nursing facilities significantly less (and
they are reimbursed more) to feed severely demented patients by
PEG tube than by hand.
Insertion
of a PEG tube for a condition other than head and neck cancer,
stroke with dysphagia for more than a month, a neuromuscular dystrophy
like ALS, or a bowel obstruction with vomiting raises medical
appropriateness concern and ethical issues. The appropriateness
of a PEG tube can be questioned, particularly when a resident
suffers a complication associated with the use of a PEG, such
as an incorrect reinsertion by a nurse that results in peritonitis
from tube feeding solution flowing into the abdomen, fluid overload
from running the tube feeding solution in too fast, or aspiration
pneumonia from vomiting and inhaling tube feeding solution. “Because
of its simplicity and low complication rate, PEG placement lends
itself to overutilization. Much of our effort in the future needs
to be directed toward the ethical aspects associated with long-term
enteral feeding. We as physicians must continuously strive to
demonstrate that our interventions truly benefit the patient.”
These are the thoughts of Dr. Gauderer, who invented the PEG tube.
[3]
At the conclusion
of this presentation by Dr. William Plonk, there was a heated
audience debate. Some of the physicians in the audience heatedly
disagreed with the conclusions of the studies. Citing descriptions
of nursing home residents who have been maintained on long term
nutrition through PEG tubes, they challenged the concerns about
PEG tubes. Dr. Plonk reiterated the findings of the studies citing
the disadvantages of PEG tubes. An attorney involved in a nursing
home PEG tube misadventure should ask: Should this tube have been
inserted at all?
References
1. Mitchell, S et al. Clinical and organizational factors associated
with feeding tube use among nursing home residents with advanced
cognitive impairment, JAMA 2003: 290: 73.
2. Ha, I,
Hague, T. Percutaneous endoscopic gastroscopy for enteral nutrition
in patients with stroke, Scand J. Gastroenterology 2003: 9:962-6.
3. Gauderer,
M. Twenty years of percutaneous endoscopic gastrostomy: origin
and evolution of a concept and its expanded applications. Surg
Endoscopy 1999, 50: 882.
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