Original Article

Effect of Physician Education and Patient Counseling on Inpatient Nonsurgical Percutaneous Feeding Tube Placement Rate, Indications, and Outcome

Authors: Arun Swaminath, MD, George F. Longstreth, MD, Eva M. Runnman, MD, Su-Jau Yang, PhD

Abstract

Background: The decision to place a percutaneous feeding tube (PFT) in patients who are at the end of life is multidimensional and often complicated. We assessed the effect of physician education and counseling for patients and their surrogates on inpatient nonsurgical (endoscopic and radiologic) PFT placement rates, indications, complications, and mortality.


Methods: In a pre-paid group practice, a geriatrician initiated a program of physician education and patient/surrogate counseling on the ethical and nutritional aspects of long-term enteral feeding. We compared rates of nonsurgical PFT placement (excluding those for cancer therapy or gastric decompression), indications, complications, and short- and long-term mortality in adult inpatients before (2004) and after (2005) the program.


Results: In 2004 and 2005, 115 and 60 inpatients underwent PFT placement, respectively. The annual number of hospital admissions was similar, but the rate of PFT placement declined (0.80% vs. 0.44%, P < 0.0001). The indications were cerebrovascular accident (42 [37%] versus 22 [37%]), dementia (15 [13%] versus 3 [5%]), other neurological disease (28 [24%] versus 16 [26%]), and miscellaneous disease (30 [26%] versus 19 [32%]); P > 0.05. Severe infectious complications occurred in 4 (3%) versus 0 (0%) patients, P > 0.05. Mortality (2004 versus 2005) at 30 days (23 [20%] versus 11 [18%]), 1 year (62 [54%] versus 29 [48%]) and 2 years (72 [63%] versus 31 [52%]) was similar, P > 0.05.


Conclusion: A pilot program of educating referring physicians and counseling patients and their surrogates reduced the rate of inpatient PFT placement by nearly 50%. Indications, severe complications and short- and long-term mortality remained unchanged.


Key Points


* Long-tem feeding through a percutaneous enteral tube is a common practice.


* In this study, a geriatrician was made available to provide value-neutral information to patients, families, and physicians when consideration was given to feeding tube placement.


* This study found a 50% decline in the rate of feeding tube placement in the year after the intervention with no significant change in the long-term mortality.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1.Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872–875.
 
2.DeLegge MH. Percutaneous endoscopic gastrostomy. Am J Gastroenterol 2007;102:2620–2623.
 
3.Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology 1995;108:1282–1301.
 
4.Cervo FA, Bryan L, Farber S. To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics 2006;61:30–35.
 
5.Bergstrom LR, Larson D, Zinsmeister AR, et al. Utilization and outcomes of surgical gastrostomies and jejunostomies in an era of percutaneous endoscopic gastrostomy: a population-based study. Mayo Clin Proc 1995;70:829–836.
 
6.Rumalla A, Baron TH. Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding. Mayo Clin Proc 2000;75:807–810.
 
7.Roche V. Percutaneous endoscopic gastrostomy. Clinical care of PEG tubes in older adults. Geriatrics 2003;58:22–26, 28–29.
 
8.Callahan CM, Buchanan NN, Stump TE. Healthcare costs associated with percutaneous endoscopic gastrostomy among older adults in a defined community. J Am Geriatr Soc 2001;49:1525–1529.
 
9.McMahon MM, Hurley DL, Kamath PS, et al. Medical and ethical aspects of long-term enteral tube feeding. Mayo Clin Proc 2005;80:1461–1476.
 
10.Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000;342:206–210.
 
11.Angus F, Burakoff R. The percutaneous endoscopic gastrostomy tube. Medical and ethical issues in placement. Am J Gastroenterol 2003;98:272–277.
 
12.Hallenbeck J. Reevaluating PEG tube placement in advanced illness. Gastrointest Endosc 2005;62:960–962.
 
13.Berger JT, DeRenzo EG, Schwartz J. Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med 2008;149:48–53.
 
14.Eisen GM, Baron TH, Dominitz JA, et al. Role of endoscopy in enteral feeding. Gastrointest Endosc 2002;55:794–797.
 
15.McCann R, Judge J. Feeding Tube Placement in Elderly Patients with Advanced Dementia. 1993. Available at: http://www.americangeriatrics.org/products/positionpapers/feeding_tube_placement.pdf. Accessed December 7, 2009.
 
16.Garrow D, Pride P, Moran W, et al. Feeding alternatives in patients with dementia: examining the evidence. Clin Gastroenterol Hepatol 2007;5:1372–1378.
 
17.Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med 2003;163:1351–1353.
 
18.Abuksis G, Mor M, Segal N, et al. Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients. Am J Gastroenterol 2000;95:128–132.
 
19.Abuksis G, Mor M, Plaut S, et al. Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience. Clin Nutr 2004;23:341–346.
 
20.Shega JW, Hougham GW, Stocking CB, et al. Barriers to limiting the practice of feeding tube placement in advanced dementia. J Palliat Med 2003;6:885–893.
 
21.Scott LD. The PEG “consult.” Am J Gastroenterol 2005;100:740–743.
 
22.Fromme E. Should my loved one get a feeding tube? J Palliat Med 2004;7:735.
 
23.Hallenbeck J. Tube feed or not tube feed? J Palliat Med 2002;5:909–910.
 
24.Givens JL, Kiely DK, Carey K, et al. Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making. J Am Geriatr Soc 2009;57:1149–1155.
 
25.Finucane TE, Christmas C, Leff BA. Tube feeding in dementia: how incentives undermine health care quality and patient safety. J Am Med Dir Assoc 2007;8:205–208.
 
26.Blendon RJ, Benson JM, Herrmann MJ. The American public and the Terri Schiavo case. Arch Intern Med 2005;165:2580–2584.
 
27.Hook CC, Mueller PS. The Terri Schiavo saga: the making of a tragedy and lessons learned. Mayo Clin Proc 2005;80:1449–1460.
 
28.Brookmeyer R, Gray S, Kawas C. Projections of Alzheimer's disease in the United States and the public health impact of delaying disease onset. Am J Public Health 1998;88:1337–1342.