Feeding Dementia Patients via Percutaneous Endoscopic Gastrostomy: Page 2 of 2
When taking into account the pros and cons of PEG placement based on the evidence in the literature, there are several key considerations that emerge. First, no patient can survive without adequate nutrition. When one removes a feeding tube without substituting another route of nutrition, death becomes imminent. PEG tube withdrawal has become an acceptable protocol in many Western countries to end the life of patients who are in a permanent vegetative state. Not feeding a dementia patient leads to the same outcome. An article by Hurley and Volicer13 about end-of-life care describes in a positive light the removal of a PEG tube in a female patient with advanced Alzheimer’s disease with the intent of causing death. PEG placement had sustained this patient’s life for more than 3 years. The patient’s daughters had the tube removed because they became dismayed by their mother’s quality of life, and she died shortly thereafter.
Second, although PEG tubes can serve as a convenient way to provide sustenance and extend life, oral feeding is preferred whenever possible. In dementia patients, oral feeding may be very costly in time and effort and is therefore often impractical in many nursing homes; however, it should be encouraged. Geriatric patients and chronically ill patients are frequently malnourished, and this condition is often not diagnosed at its early stages. There should be ongoing evaluation of dementia patients for the earliest signs of undernutrition. Oral feeding is obviously the ideal route to maintain adequate nutrition whenever possible, but at the earliest signs of malnutrition, alternate methods of feeding should be considered before more serious debilitating conditions develop, which may render PEG placement futile. We have previously made these recommendations in the medical literature.14
A third consideration is that complications associated with PEG placement are likely to be more frequent and more serious in patients with advanced diseases. If the decision to use parenteral feeding is delayed until the serum albumin level drops too low, wound healing will likely be impaired and infections will be more likely to occur. This is why we support close monitoring of nutrition status in patients with dementia, even in the early stages when self-feeding is still possible. When malnutrition is discovered early, it can be addressed while the risk of complications is lower and outcomes are more likely to be improved.
Finally, until there is more substantial evidence on the potential benefits and harms of PEG tube feeding in elderly dementia patients, the decision to use or end this kind of long-term nutritional support in end-of-life care appears to belong to patients and their family caregivers in keeping with their personal and cultural preferences.
Based on the currently available literature, it is clear that more research on when and for whom to implement PEG feeding is needed, particularly in the setting of dementia care. In a 2009 Cochrane review, Sampson and colleagues15 found that no randomized controlled trials and only seven observational controlled studies have been conducted to evaluate outcomes of enteral tube feeding for older people with advanced dementia who develop problems with eating and swallowing and/or have poor nutritional intake. None of these seven studies showed conclusive evidence of prolonging survival or improving quality of life, and none fully explored adverse effects of enteral feeding in this specific patient population. The researchers urged, “This area is difficult to research but better designed studies are required to provide more robust evidence.” We strongly endorse this recommendation, especially the need for randomized controlled trials, before concluding whether PEG tube feeding in dementia patients can and should be used to prolong life. Specifically, we suggest that patients who cannot be adequately nourished through oral feedings be divided prospectively and randomly into two grouops: one to be fed by PEG and the other not. One might then learn whether there are specific subgroups of patients with dementia in whom the balance of benefit/risk favors use of PEG and perhaps others who reap no benefits.
Several seminal papers reporting unfavorable results following PEG placement in patients with advanced dementia have led to the widespread conclusion that the use of enteral feedings in patients with dementia is not indicated. But other reports and experiences raise questions about these categoric conclusions. We urge clinicians to take a more nuanced
position until prospective randomized controlled studies to differentiate between subgroups of patients with dementia with varying benefit/risk ratios are undertaken to shed more conclusive light on this issue.
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2. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;282(14):1365-1370.
3. DeLegge MH. Tube feeding in patients with dementia: where are we? Nutr Clin Pract. 2009;24(2):214-216.
4. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342(3):206-209.
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6. Callahan CM, Haag KM, Weinberger M, et al. Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 2000;48(9):1048-1054.
7. Finucane TE, Christmas C. More caution about tube feeding. J Am Geriatr Soc. 2000;48(9):1167-1168.
8. Lindemann B, Nikolaus T. Outcomes of percutaneous endoscopic gastrostomy in dementia patients. J Am Geriatr Soc. 2001;49(6):838-839.
9. Shapiro DS, Friedmann R. To feed or not to feed the terminal demented patient: is there any question? Isr Med Assoc J. 2006;8(7):507-508.
10. Clarfield AM, Monette J, Bergman H, et al. Enteral feeding in end-stage dementia: a comparison of religious, ethnic, and national differences in Canada and Israel. J Gerontol A Biol Sci Med Sci. 2006;61(6):621-627.
11. Norberg A, Hirschfeld M, Davidson B, et al. Ethical reasoning concerning the feeding of severely demented patients: an international perspective. Nurs Ethics. 1994;1(1):3-13.
12. Higaki F, Yokota O, Ohishi M. Factors predictive of survival after percuataeous endoscopic gastrostomy in the elderly: is dementia really a risk factor? Am J Gastroenterol. 2008;103(4):1011-1016.
13. Hurley AC, Volicer L. Alzheimer Disease: “It’s okay, Mama, if you want to go, it’s okay.” JAMA. 2002;288(18):2324-2331.
14. Jotkowitz AB, Clarfield AM, Glick S. The care of patients with dementia: a modern Jewish ethical perspective. J Am Geriatr Soc. 2005;53(5):881-884.
15. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009;2:CD007209.
The authors report no relevant financial relationships.
Address correspondence to:
Shimon M. Glick, MD
Faculty of Health Sciences