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 for help with your next PEG tube or nursing home
case. We can assist with location of nursing
and physician
experts, retrieval of articles supporting the standard
of care, preparation of timelines and chronologies,
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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