When a patient can no longer eat or drink, liquid food or fluids can be given by a tube inserted in the stomach through the skin on the abdomen or fluids can be given by a small plastic tube (catheter) inserted directly into the vein. If a patient chooses not to have either a feeding tube or IV fluids, food and fluids are offered as tolerated using careful hand feeding.
A tube inserted in the stomach through the skin on the abdomen is called a Percutaneous Endoscopic Gastrostomy (PEG) tube and provides artificially administered nutrition. The decision to have a PEG tube placed in an individual is one that must take into account the patient’s health status, prognosis, values, beliefs and goals for care.
It is the physician’s or nurse practitioner’s responsibility to speak with the patient having difficulty swallowing or eating, (or the health care agent or surrogate) in an honest and compassionate manner and review all potential outcomes which can reasonably be anticipated as a result of placement of a PEG. The family should be part of the discussion.
The Guidelines on Tube Feeding/Percutaneous Endoscopic Gastrostomy (PEG) Tubes for Adults were originally developed to support thoughtful MOLST discussions and shared medical decision making based on current disease-specific medical evidence and ethical-legal requirements.
The Guidelines aim to provide data, information and tools to physicians, nurse practitioners, other clinicians, patients, families, health care agents, and surrogates to help fully inform the evaluation and shared decision-making process around the use of tube feeding/PEG placement for the adult population, including persons with developmental disabilities, given the health status, prognosis, values, beliefs and goals for care of the individual patient.
The Guidelines on Tube Feeding/Percutaneous Endoscopic Gastrostomy (PEG) Tubes for Adults were developed by a panel of experts and aim to help physicians and nurse practitioners with shared decision making by recognizing current disease-specific medical evidence and ethical-legal requirements.
Prior to initiating tube feeding, a global assessment an adult patient who is unable to maintain nutrition should be completed. The goal of the assessment is to identify and treat potentially reversible causes of inadequate nutrition. If treatment of potentially reversible causes does not result in improved nutrition, the physician or nurse practitioner must have a discussion with the patient about options. This discussion begins with ensuring the patient understands their medical condition and prognosis, and the physician or nurse practitioner understands the patient’s values, beliefs and goals of care for care. Often, decreased nutrition is a marker for progressive illness, and instituting artificial feeding will not improve mortality or comfort.
The benefits and burdens of PEG placement vary depending upon the individual’s current health status and prognosis. Benefits and burdens of PEG tubes should be assessed as to whether or not they are likely to achieve specific patient goals:
Medical evidence has shown that placing a PEG tube in an individual will not decrease the likelihood of aspiration pneumonia, will not assist in healing pressure sores, and has been associated with increased use of medication and hospitalization. In fact, the risk of aspiration pneumonia is the same or greater for an individual with a PEG as compared to an individual handfed.
The benefits and burdens grid lists the relative likelihood of these occurring for PEG placement in individuals who have had a stroke, have amyotrophic lateral sclerosis (ALS) known as Lou Gehrig’s disease, advanced dementia, advanced cancer or advanced organ failure as well as those who are frail or in a persistent vegetative state. The information in this grid is based upon consensus of experts in the field and attempts to provide a concise summary of this as a framework for discussion with individuals considering a PEG.
When it is decided to initiate tube feeding it should be with specific goals for care in mind which are reviewed at regular intervals. Because the benefits or failures of tube feeding are likely to occur within 3-6 months following placement, periodic assessment is most important. Reassessments should focus on the achievement of specific goals of therapy identified with initial PEG placement.
The Guidelines on Tube Feeding/Percutaneous Endoscopic Gastrostomy (PEGs) for Adults were originally developed by the PEGs Workgroup initially in 2004. The Guidelines were reviewed and revised by the PEGs Workgroup and approved by the Monroe County Medical Society Quality Collaborative in April 2017 with the next scheduled update in 2019. Special thanks to the PEG Tube Workgroup.
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