The percutaneous endoscopic gastrostomy tube: medical and ethical issues in placement

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Abstract
Offering and recommending PEG tube placement to patients has been a topic of considerable interest in the medical literature. The role of individual health care professionals in the decision making process is poorly defined. PEG tubes are often placed inappropriately because of unrealistic and inaccurate expectations of what they can accomplish in patients unable to tolerate adequate oral intake. We have developed an algorithm for PEG placement for the geriatric, oncology, and neurology patients based on a critical review of current literature. An extensive review of the literature was performed focusing on PEG tube placement in oncology, neurology, and geriatric patients. This algorithm was developed to provide both the primary care provider and the specialist with appropriate indications for PEG placement in these patient populations. Appropriate indications for PEG placement are 1) Esophageal obstruction (e.g., esophageal cancer), 2) Neurologic etiology of dysphagia without obstruction (e.g., status post cerebrovascular accident, pseudobulbar palsy), 3) Prolonged refusal to swallow without evidence of concomitant terminal illness (e.g., protracted pseudodementia due to severe depression), 4) Supplemental nutrition for patients undergoing chemotherapy or radiation therapy. If no physiologic benefit is expected with PEG placement (anorexia-cachexia syndrome), the health care team has no obligation to offer or perform an intervention. This same principle would apply if intervention improves physiologic states but has no effect on quality of life (e.g., permanent vegetative state). Small-bore feeding tubes are cost effective and relatively safe for enteral feedings of up to 6-8 weeks. This is especially pertinent in the population with acute neurological deficits, in which prognostication on extent of impairment is best estimated by communication with neurologist. In the geriatric population there is no proved benefit in weight gain or markers of nutrition (albumin, prealbumin) in patients with malnutrition due to impaired oral intake.