These numbers do not account for long-term complications including peristomal infections, leakage problems, or the use of physical restraints to avoid self-extubation.
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Aspiration Risk
A common indication for PEG placement is aspiration risk. PEG tubes are often placed in patients who fail swallowing evaluations in order to decrease their risk of aspiration and aspiration pneumonia.
True aspiration pneumonia is thought to originate from an inoculum of oral cavity or nasopharynx bacteria, which placement of a PEG tube would not prevent. Leibovitz, et al., showed that elderly patients with nasogastric or percutaneous feeding tubes are associated with colonization of the oropharynx with more pathogenic bacteria when compared with orally fed patients.5 Thus, the use of PEG tubes might put them at higher risk for pathogenic inoculation.
Aspiration pneumonia occurs in up to 50% of patients with feeding tubes. Studies have shown PEG tube placement decreases lower esophageal sphincter tone, potentially increasing regurgitation risk.6 It has also been shown that aspiration of gastric contents produces a pneumonitis with the resultant inflammatory response allowing for establishment of infection by smaller inoculums of or less virulent organisms.7
Small, randomized trials have shown no decrease in aspiration risk with post-pyloric versus gastric feeding tubes, nasogastric versus percutaneous feeding tubes, or continuous versus intermittent tube feeds.8 There have been no sizable randomized prospective trials to determine if feeding tube placement versus hand feeding patients with end-stage dementia alters aspiration pneumonia risk.
Pressure Ulcers
Patients with end-stage dementia often become bed bound as their disease progresses, and they commonly suffer from pressure ulcers. Pressure ulcers often coexist in patients with malnutrition, and it is well established that patients with biochemical markers of malnutrition are at higher risk for pressure ulcer formation.
Still, no studies show that improved nutrition prevents pressure ulcer formation. In a nursing home population of patients with dementia, a two-year follow-up study showed no significant improvement in pressure ulcer healing or decreased ulcer formation with nutrition by feeding tube.9 These studies are adjusted for independent risk factors for mortality and indication for PEG placement, but we can assume there are confounders that go into the decision for feeding tube placement that are not necessarily identifiable.
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Nutritional Status
Family members are often concerned that if the patient is unable to take food by mouth and no feeding tube is placed, then the patient will suffer from the discomfort of starvation and dehydration.
As a patient with a severe dementing illness enters the end stage of his/her clinical course, practitioners frequently make a plan with families to change the goals of care toward keeping the patient comfortable. Comfort is a difficult clinical parameter to measure, but studies in the hospice population of patients with end-stage cancer and AIDS report that the hunger and thirst are transient and improve with ice chips and mouth swabs.10
Despite the lack of evidence of PEG tubes prolonging survival in patients with dementia who are no longer able or willing to take in food orally, it is logical that withholding all hydration or nutritional support will hasten death despite the risks associated with feeding tubes. This is where the ethical argument arises regarding prolonging life of decreasing quality.
In certain medical and legal sectors, artificial nutrition, and hydration are considered a medical intervention. Therefore, the ideals of patient autonomy dictate that the patient’s proxy should decide whether or not the patient would have wanted the intervention after weighing the risks and benefits.
If hospitalists view artificial nutrition as a medical intervention, our moral obligation is to instruct patients and their families about these risks and benefits.