To Tube or Not to Tube

The ability to maintain nutrition and hydration is essential when caring for hospitalized older adults. When physicians recognize that long-term nutrition and hydration cannot be maintained through an oral route, percutaneous endoscopic gastrostomy (PEG) tube placement may need to be considered for long-term nutritional support. This decision is often distressing for the patient, family, and physician for several reasons.

First, the significant number of competing benefits, risks, and burdens of long-term enteral feeding that have to be considered can be overwhelming. The second reason is the lack of clinical data regarding outcomes of PEG tubes for many patients. The last and usually most distressing reason in the decision of PEG tube feeding involves the cultural, ethical, and religious beliefs involved in this decision.

For many families and physicians providing nutrition, including enteral nutrition, using a PEG tube symbolizes compassion, love, and care. This is because eating represents one of the most basic of human needs. For some, not providing nutrition with a PEG tube is morally and ethically wrong. Withholding PEG tube placement can be perceived as assisted suicide or murder. Some physicians also fear legal, ethical, or religious misconduct should they decide against tube feeding.

Physicians need not fear the legal consequences of discontinuing life-sustaining treatment if an appropriate decision-making process has been followed.1 An adult patient who has decision-making capacity and is appropriately informed has the right to forego any forms of medical therapy including life-sustaining therapy such as PEG tube feeding.2

Deciding whether or not to recommend PEG tube feeding can be accomplished in a series of steps. The first step is to evaluate the clinical benefits, risks, and burdens of long-term nutrition for the individual patient. The second step involves discussing the patient’s life goals with them and their family. On many occasions, the decision to place a PEG tube will be made by a surrogate decision-maker such as the patient’s spouse or child. Usually discussions about nutrition and hydration by PEG tube will occur between patients, families, and physicians when the overall end-of-life goals are reviewed. A physician’s role includes assisting patients and their families by providing information and a clear recommendation for or against the use of a feeding tube, giving alternative options, and ensuring there is true informed consent prior to feeding tube insertion.

The most frequent indication for long-term PEG tube feeding is a neurological disorder such as a stroke.3 PEG tube feeding has been developed as a practical alternative to parental feeding for patients with a functioning gastrointestinal (GI) tract who lack the ability to take food by mouth. PEG tube feeding is considered a medical intervention and, like any other intervention, has to be considered according to specific patient situations.

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