February 08, 2010
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"Tube Feeding" — Right or Wrong: The Medical, Legal and Ethical Issues
David E. Milkes, M.D.
Dr. Milkes is Fellow, Gastroenterology and Hepatology, Stanford University Medical Center, and reports no commercial conflict of interest.
Most of us know it as "tube feeding." Doctors call it percutaneous endoscopic gastrostomy (PEG). Compared with most kinds of surgery, it is a safe, uncomplicated and almost routine procedure. But simple or not, PEG is the focus of some extremely complex legal and ethical questions. Why? Because unlike nearly every other method of feeding, PEG feeding does not require the cooperation or consent of the person being treated. In effect, PEG is a form of forced feeding. Since their development a quarter century ago at the Rainbow Babies and Children's Hospital in Cleveland, PEG tubes have become widely used. Originally designed to provide nourishment to children who were unable to swallow because of neurological problems, PEG tubes are now frequently used in adults who have diseases or conditions that make it difficult to swallow or eat voluntarily. Most patients receiving PEGs are elderly — between 1988 to 1995, the number of elderly hospitalized patients undergoing the procedure increased from 61,000 to 121,000.(1) Though the procedure is fairly routine medically, there are many complex issues surrounding PEG use, particularly for patients near the end of life, where the decision to use or not to use a PEG is frequently made without the participation of the patient. The ethical picture is further clouded by several studies that question the medical benefit of PEGs in elderly demented patients, a group that receives a high percentage of the PEG procedures currently done. Other studies have found a surprisingly high death rate for these patients within one month of being given a PEG. For all of these reasons, it is important for patients, friends and family to have a full discussion with their doctor before any decision is made about using a PEG. The goal should be a clear understanding of the medical goals and moral reasons for going ahead with a PEG placement. The Surgical Procedure
Local anesthesia is used to numb the throat. A flexible, lighted instrument called an endoscope is threaded to the stomach through the mouth, throat and esophagus. A skin incision is made through the abdomen and a needle introduced into the stomach. A snare is passed down the endoscope in order to capture a wire or suture that has been placed through the needle. A feeding tube, through which food will be sent directly into the stomach, is advanced over the wire into the stomach. Feedings can be started as soon as the next day.
What Are PEGs For?
In general, PEGs are placed to provide nutrition for patients who cannot or will not eat, and who have a normally functioning gastrointestinal tract.(3) The most common reasons are head trauma, stroke, collagen vascular disorders and neurological disease.(4) Other reasons include obstruction caused by head, neck or esophageal cancers.(5) Depressed patients who refuse to eat may also benefit from tube feedings while their underlying psychiatric problems are treated.
Patients should not be subjected to a PEG unless they are expected to require feeding for greater than 30 days.(6) Those with a life expectancy of less than 30 days or who will only require short-term feeding should be fed via a nose, or nasogastric feeding tube.(7) The reason for this is to spare patients with a grave prognosis or limited need for tube feedings the expense and risk of an unnecessarily invasive procedure. Medical Complications of PEGs
The complications occurring with PEG placement can be divided into minor and major categories (see Table 1).
Table 1.
Complications from PEG.
Most complications are minor and occur in approximately 5-10% of cases.(8) Usually, these consist of easily treatable and uncomplicated wound infections, bleeding or abdominal pain.(9) PEGs can become clogged. Accidental or deliberate removal of the tube by the patient is another common complication. Patients may require restraints in order prevent them from pulling on the tube.(10) Major complications are rare, occurring in only 1-2% of cases.(12) The overall mortality rate of PEG procedures is 0.3-1%. The risk of death increases markedly with age. Infection is a rare, though a potentially serious complication. Even rarer complications are severe bleeding and intestinal obstruction.(13)
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Comment by: A Stanley
Sun., Jan. 24, 2010 at 10:16 am EST Very informative article.
Comment by: Amma
Sun., Jan. 17, 2010 at 8:53 pm EST Thank you for posting these articles about the PEG. I found them very helpful and insightful. We are facing the decision and don't know whether or not to have the tube removed from my 90 yr. old mother who got the PEG after having a stroke a year ago. Rehab was tough and unsuccessful. Before the stroke, she was still living independently and mentally sharp. Now she is completely bedridden, not yet fully demented--remembers family and things, has no interest in eating or in anything else, and is always in pain and medicated. It's painful to see what she's become, and we don't want her to suffer anymore.
Comment by: shirley
Sat., Jan. 2, 2010 at 6:36 pm EST i had cancer in my toncils and by radiation i cannot swallow. ihad a peg since 2003. i am no 59 years old. how long or great are my chances of keeping my peg at old age (about 80+) is there an alternative to this problem? |
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