Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals

A bridge to cross: Tube feeding and the barriers to implementation of palliative care for the advanced dementia patient

AIMS AND OBJECTIVES

To elucidate the attitudes and knowledge of nursing home (NH) staff involved in the decision-making process surrounding tube feeding for people with advanced dementia, and regarding palliative care and eating difficulties in this population.

BACKGROUND

Dementia's final stage is associated with eating difficulties. "Comfort feeding" is the approach endorsed by the American Geriatrics Society for those with advanced dementia and eating difficulties. Despite this, tube feeding remains a persisting practice in NHs in Israel.

DESIGN

A qualitative descriptive study.

METHODS

Twenty-seven NH employees from different sectors employed by seven NHs in northern Israel underwent semi-structured, face-to-face interviews. The COREQ checklist was used to aid with reporting and analysis of results.

RESULTS

In Israel, there is an emerging palliative care discourse in caring for people with advanced dementia living in the NH setting. However, many interviewed did not demonstrate an accurate understanding of this term or of the term "comfort feeding." Several barriers towards implementation of palliative care were identified and include a lack of formal education regarding nutrition in advanced dementia, socio-economic factors and their association with the two types of NHs operating in Israel (those with exclusively private funding and those reimbursed by the Ministry of Health).

CONCLUSIONS

Interviews with NH staff regarding eating difficulties in advanced dementia shed light on the palliative care discourse, which is in a liminal stage in many countries. The themes that emerged may help inform future recommendations regarding palliative care in general and more specifically in NH residents with advanced dementia, in countries where policy is still being developed and refined.

RELEVANCE TO CLINICAL PRACTICE

Understanding barriers towards implementation of a palliative approach and comfort feeding specifically could improve the care for people with advanced dementia in the NH setting.

High In-hospital mortality after percutaneous endoscopic gastrostomy: results of a nationwide population-based study

BACKGROUND & AIMS

It is important to carefully select patients who undergo endoscopic procedures, to optimize health care. Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive endoscopic procedure that has been associated with high short-term mortality. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among patients undergoing PEG.

METHODS

We conducted a nested, case-control, retrospective study using the US Nationwide Inpatient Sample (NIS) to analyze data from all hospitalizations in 2006 with an International Classification of Diseases, 9th revision, procedure code for PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality after the procedure. A separate analysis using a propensity score matching technique was conducted to compare mortality with a control cohort. Results were validated in an independent analysis of 2007 NIS data.

RESULTS

In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006 (95% confidence interval, 10.3%-11.3%). Odds of death increased with age (1%/y), congestive heart failure, renal failure, chronic pulmonary disease, coagulopathy, pulmonary circulation disorders, metastatic cancer, and liver disease. The indication for PEG was associated strongly with mortality. Women and patients with diabetes mellitus or paralysis had a lower risk of death. PEG was associated with slightly higher odds of in-hospital mortality compared with patients who did not undergo PEG. Qualitatively and quantitatively similar results were obtained when 2007 NIS data were analyzed.

CONCLUSIONS

The mortality rate is almost 11% among hospital inpatients after PEG. We have identified factors that increase and decrease the risk of death after PEG; these factors could improve patient selection for those most likely to benefit from this procedure.

How are treatment decisions made about artificial nutrition for individuals at risk of lacking capacity? A systematic literature review

BACKGROUND

Worldwide, the number of individuals lacking the mental capacity to participate in decisions about their own healthcare is increasing. Due to the ageing global population and advancing medical treatments, there are now many more people living longer with neurological disorders, such as dementia, acquired brain injuries, and intellectual disabilities. Many of these individuals have feeding difficulties and may require artificial nutrition. However, little is known about the decision-making process; the evidence base is uncertain and often ethically complex. Using the exemplar of artificial nutrition, the objective of this review is to examine how treatment decisions are made when patients are at risk of lacking capacity.

METHODS AND FINDINGS

We undertook a systematic review according to PRISMA guidelines to determine who was involved in decisions, and what factors were considered. We searched PubMed, AMED, CINAHL, EMBASE, PsychINFO, and OpenSigle for quantitative and qualitative studies (1990-2011). Citation, reference, hand searches and expert consultation were also undertaken. Data extraction and quality assessment were undertaken independently and in duplicate. We utilised Thomas and Harden's 'Thematic Synthesis' for analysis. Sixty-six studies met inclusion criteria, comprising data from 40 countries and 34,649 patients, carers and clinicians. Six themes emerged: clinical indications were similar across countries but were insufficient alone for determining outcomes; quality of life was the main decision-making factor but its meaning varied; prolonging life was the second most cited factor; patient's wishes were influential but not determinative; families had some influence but were infrequently involved in final recommendations; clinicians often felt conflicted about their roles.

CONCLUSIONS

When individuals lack mental capacity, decisions must be made on their behalf. Dynamic interactive factors, such as protecting right to life, not unnecessarily prolonging suffering, and individual preferences, need to be addressed and balanced. These findings provide an outline to aid clinical practice and develop decision-making guidelines.

Long-term nasogastric tube feeding in elderly stroke patients--an assessment of nutritional adequacy and attitudes to gastrostomy feeding in Asians

BACKGROUND

Gastrostomy feeding is superior to long-term nasogastric (NG) feeding in patients with dysphagic stroke, but this practice remains uncommon in Asia. We sought to examine the nutritional adequacy of patients on long term NG feeding and identify barriers to gastrostomy feeding in these patients.

METHODOLOGY

A prospective comparison of subjective global assessment (SGA), and anthropometry (mid-arm muscle circumference, MAMC; triceps skinfold thickness, TST) between elderly stroke patients on long-term NG feeding and matched controls was performed. Selected clinicians and carers of patients were interviewed to assess their knowledge and attitudes to gastrostomy feeding.

RESULTS

140 patients (70 NG, 70 oral) were recruited between September 2010 and February 2011. Nutritional status was poorer in the NG compared to the oral group (SGA grade C 38.6% NG vs 0% oral, p<0.001; TST males 10.7 + 3.7 mm NG vs 15.4 + 4.6 mm oral, p<0.001; MAMCmales 187.9 + 40.4 mm NG vs 228.7 + 31.8 mm oral, p<0.001). 45 (64.3%) patients on long-term NG feeding reported complications, mainly consisting of dislodgement (50.5%), aspiration of feed content (8.6%) and trauma from insertion (4.3%). Among 20 clinicians from relevant speciliaties who were interviewed, only 11 (55%) clinicians would routinely recommend a PEG. All neurologists (100%) would recommend a PEG, whilst the response was mixed among non-neurologists. Among carers, lack of information (47.1%) was the commonest reason stated for not choosing a PEG.

CONCLUSION

Elderly patients with stroke on long term NG feeding have a poor nutritional status. Lack of recommendation by clinicians appears to be a major barrier to PEG feeding in these patients.

Feeding tube placement in patients with advanced dementia: the beliefs and practice patterns of speech-language pathologists

PURPOSE

To describe the beliefs and practices of speech-language pathologists (SLPs) about the use of percutaneous endoscopic gastrostomy (PEG) among patients with advanced dementia and dysphagia.

METHOD

A survey was mailed to a geographically stratified random sample of 1,050 medical SLPs.

RESULTS

The response rate was 57%, and 326 surveys met inclusion criteria. Fifty-six percent of SLPs recommended PEG for a patient with advanced dementia and dysphagia. Contrary to the evidence, many respondents believed that PEG improves nutritional status and increases survival. Relatively few SLPs believed that PEG improved patients' functional status or quality of life. Patient factors (e.g., age or prognosis) were more often identified as influences on recommendations for PEG than were extrinsic factors (e.g., cost). Nearly 40% believed that PEG was the standard of care, while 15% believed it should be. Very few SLPs (11%) would want a PEG themselves. Perceived standard of care was significantly related to both geographic region and population density (p < .05), but self-reported practices were not.

CONCLUSIONS

Discrepancies between SLPs' beliefs, the literature, and self-reported practices were observed. The findings suggest the need to connect the evidence base to clinical practice and to include SLPs in local and national discussions about end-of-life care protocols.

Resolving End-of-Life Ethical Concerns: Important Palliative Care Practice Development Issues for Acute Medicine in Australia

Historically palliative care research has focused on issues associated within the hospice and palliative care system. The findings presented in this manuscript reverse this assumption to argue that significant palliative care issues can only be understood if the focus is on the acute care system. Although a major proportion of deaths happen in the acute hospital setting, the acute care clinicians are the gate keepers to the palliative system. In short, understanding the ethical decision making of acute care professionals in relation to end-of-life care can illuminate many important palliative care practice development issues. The findings indicate that all professional groups in this study of an acute medical ward find end-of-life issues the most challenging of all the ethical challenges.

Prevalence and associated factors of pneumonia in patients with vegetative state in Taiwan

AIMS

The aim of this study was to investigate the prevalence rate and influencing factors of pneumonia associated with long-term tube feeding in special care units for patients with persistent vegetative states (PVS) in Taiwan.

BACKGROUND

Pneumonia is a significant cause of morbidity, hospitalization and mortality in the nursing home population. Tube feeding has been found as a risk factor for the occurrence of pneumonia.

METHODS

Two hundred sixty subjects were chosen from three hospital-based special care units for patients with PVS and 10 nursing facilities for persons in PVS in Taiwan. All subjects, who were diagnosed with PVS, received either financial aid for institutional care or were means-tested from The Bureau of Social Welfare of cities and counties in Taiwan. Data were collected through chart review and observations.

RESULTS

The prevalence rate of pneumonia in nursing facilities for patients with PVS was 14.2%. The prevalence rate of tube-feeding in nursing facilities for PVS was 91.2%. The mean duration of tube-feeding was 73.21 SD 55.33 months. A total of 90.4% was fed with a nasogastric (NG) tube. Having a lower intake of food and fluids daily and having been institutionalized for a shorter period were three dominant factors associated with the occurrence of pneumonia.

CONCLUSION

Research findings reveal that the incidence of pneumonia is higher in patients who do not receive adequate food and water. Continuing in-service training to improve caregivers' knowledge and skill in providing care to patients in PVS and monitoring their skills in feeding is needed to decrease the occurrence of pneumonia in this population.

RELEVANCE TO CLINICAL PRACTICE

Staff needs to be taught to monitor laboratory data and signs and symptoms of malnutrition and hydration deficit, and also be alert to early indicators of pneumonia in patients with PVS.

PEG-Ernährung bei fortgeschrittener Demenz

Lacking clear empirical evidence and ethical obligations, decision-making about tube-feeding in patients with advanced dementia often presents as a difficult problem in clinical routine. Based on the principles of beneficence, non-maleficence and autonomy, an ethical analysis of the empirical evidence shows that tube-feeding should be avoided in many patients with advanced dementia: Recent studies demonstrate (1) that there is no proof of any benefit, (2) that tube-feeding often results in further harm to the dementia patient and (3) that the patient's will is not sufficiently taken into consideration. A practical model for interdisciplinary decision-making can account for these various difficulties and might improve the empirically and ethically highly complex process of decision-making about tube feeding in patients with advanced dementia.

Percutaneous endoscopic gastrostomy (PEG): the role and perspective of nurses

AIMS AND OBJECTIVES

To study the perspectives of nurses on (i) the process of decision-making regarding the placement of feeding gastrostomies, (ii) their role in the process, (iii) the impact this participation has on them personally and (iv) gastrostomy placement in general.

BACKGROUND

The decision to commit patients to long-term feeding using a gastrostomy tube can be very difficult, particularly when the anticipated benefits are uncertain. Strategies to improve such decision-making are required. Nurses are in an excellent position to provide valuable insights regarding this decision-making and their increased participation in this process might substantially improve it.

DESIGN

A cross-sectional, exploratory design using in-depth semi-structured interviews and a self-administered questionnaire.

METHODS

In-depth semi-structured interviews with 17 nurses experienced in percutaneous endoscopic gastrostomy decision-making were undertaken and analysed.

RESULTS

Individuals making decisions regarding feeding gastrostomy placement were observed to be insufficiently informed regarding the device and the ramifications of its placement. Nurses were perceived to play an important, although underused, role in decisions to commit patients to long-term feeding. Participation in the making of these decisions may be stressful to nurses, particularly when the only result anticipated is the sustaining of a life of poor quality. Sixteen nurses reported that they would not want to have a gastrostomy for themselves if they were unable to maintain some quality of life. Strategies that could improve decision-making were suggested.

CONCLUSIONS

Decision-making could be improved by providing better information to decision makers. A team-orientated approach and more active dialogue with regard to care planning among health professionals, especially between doctors and nurses is needed. Effective decisions regarding feeding gastrostomy placement require adequate resources, especially sufficient time for caregivers to communicate effectively with those who must make these decisions.

RELEVANCE TO CLINICAL PRACTICE

The role of nurses in decision-making regarding commitments to long-term feeding using gastrostomy tubes could be effectively augmented.

Percutaneous endoscopic gastrostomy in cognitively impaired older adults: a geropsychiatric perspective

The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.

Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in two district general hospitals in the United Kingdom

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) is the accepted method for long-term enteral nutrition. Recent studies have suggested a higher mortality than was initially reported. The demands for gastrostomy insertion have risen, encompassing indications where the long-term outcomes are uncertain. We, therefore, constructed guidelines to try and improve the appropriateness of patient selection. Our aim was to prospectively assess the impact of guidelines for PEG insertion over a 1-yr period in a single center, Rotherham District General Hospital (hospital A) and compare against an adjacent center serving a similar population, Doncaster Royal Infirmary (hospital B) where guidelines had not been instituted.

METHODS

Data were collected from June, 1998 to May, 1999. Indication for PEG was documented and survival analysis performed using the Kaplan-Meier survival method.

RESULTS

The number of PEG insertions had been rising each year in both centers. After guidelines were introduced in hospital A, the number of procedures fell by 20, whereas in hospital B, the PEG insertion rate continued to rise (p = 0.02). There was a lower mortality observed in hospital A (at 1 month, 16%; at 3 months, 26%; at 6 months, 39%; and at 1 yr, 46%) than in hospital B (at 1 month, 26%; at 3 months, 44%; at 6 months, 58%; and at I yr, 68%), although this did not achieve statistical significance (log rank test, p = 0.1).

CONCLUSIONS

This is the first study to prospectively assess the impact of guidelines and a proactive role in the decision for PEG insertion. Fewer procedures were performed, and there was a trend toward a reduction in mortality.

Tube feeding patients with advanced dementia: an ethical dilemma

Many patients with dementia lose the ability to feed themselves in the advanced stages of the disease. Tube feeding is sometimes initiated to overcome feeding difficulties. Recent studies have questioned the appropriateness of tube feeding in these patients. There is limited research to support the benefits of enteral nutrition in patients with advanced dementia. Deciding whether to tube feed or to withhold tube feeding from a patient with dementia poses a difficult challenge, and many carers may make decisions without adequate information and with an overly hopeful view of the future clinical course. Numerous studies have examined opinions about life-sustaining treatments; many individuals do not want to be tube fed if they were to develop dementia. Results from studies examining the opinions of physicians and other health professionals regarding the use of tube feeding in these patients are conflicting. A number of factors, such as race and cultural background may affect decisions. Healthcare professionals, relatives and patients must be aware of the realistic expectations of tube feeding in patients with dementia, as it can be difficult to withdraw once it has been initiated.

Percutaneous endoscopic gastrostomy: psychological effects

A mainly qualitative study, with some quantitative measurement tools, was undertaken to explore the psychological effects of percutaneous endoscopic gastrostomy (PEG) feeding on both patients and carers. A significant level of depression and stress was found in patients whose lifestyle had changed greatly; this was due partly to having to use a PEG and part to the underlying disease. Patients were, at the same time, grateful for the benefits to their nutritional state of having a PEG. A high level of stress was experienced by the relatives of patients whose functional and/or mental abilities had significantly changed for the worse and who had had a PEG tube placed. A need for more initial factual information and for ongoing practical and psychological support for both patients and carers was identified.