Medical Orders for Life-Sustaining Treatment - Professionals
Guidelines for Long Term Feeding Tube Placement
The Community-wide Clinical Guidelines on Percutaneous Endoscopic Gastrostomy (PEGs)/Tube Feeding were developed by the Percutaneous Endoscopic Gastrostomy PEGs Workgroup initially in 2004. The Guidelines were reviewed and revised by the PEGs Workgroup and approved by the Quality Collaborative in 2013 with the next scheduled update in 2015.
The choice to have a PEG placed in an individual is one that is heavily value laden. It is the clinician’s responsibility to present to the individual having difficulty swallowing or eating, (or the family or health care agent) in a straightforward, objective manner, all major outcomes which can reasonably be anticipated as a result of placement of a PEG.
Approach to an Adult Unable to Maintain Nutrition
Prior to initiating tube feeding, a global assessment should be completed to identify potentially reversible causes for inadequate nutrition. If intervening on potentially reversible causes of not eating doesn’t result in improved nutrition a discussion should take place with the family and or patient to determine a course of action. This discussion should include elements of prognosis, patient values and goals of care in light of the patient’s condition. Often, decreased nutrition is a marker for progressive illness, and instituting artificial feeding will not improve mortality or comfort.
When it is decided to initiate tube feeding it should be with specific goals in mind which are reviewed at regular intervals.
Because the benefits or failures of tube feeding are likely to occur within 3-6 months following placement, periodic assessment is most important. Reassessments should focus on the achievement of specific goals of therapy identified with initial PEG placement.
Benefits and Burdens of PEG Placement
The benefits and burdens of PEG placement vary depending upon the individual’s current problems and/or disease state and prior health status. Benefits and burdens in the following domains should be assessed as to whether or not they are likely to be achieved or not: enabling an individual to live longer, have an improved quality of life and functional status and/or reverse the disease process or enable potentially curative therapy to occur.
Conventional wisdom says that pacing a PEG in an individual will decrease the likelihood of aspiration pneumonia and/or skin wounds. The evidence does not support this. In fact, the risk of aspiration pneumonia is the same or greater for an individual with a PEG as compared to an individual handfed.
The benefits and burdens grid lists the relative likelihood of these occurring for PEG placement in individuals who have had a stroke, have amyotrophic lateral sclerosis, advanced dementia, advanced cancer or advanced organ failure as well as those who are frail or in a persistent vegetative state. The information in this grid is based upon consensus of experts in the field and attempts to provide a concise summary of this as a framework for discussion with individuals considering a PEG.
Consumer Resources to Assist in Making a Decision about PEGs
Given the complexities surrounding the decision to have a PEG or not, it is critical that clinicians avail themselves of materials to help the individual and/or his or her loved ones or health care agent understand what a PEG is and the benefits and burdens of having one. The following are useful resources.
- Community-wide Clinical Guidelines on Percutaneous Endoscopic Gastrostomy (PEGs)/Tube Feeding (2013)
- Handbook for Mortals
- Making Choices: Long-Term Feeding Tube Placement in Elderly Patients: Booklet
- Making Choices: Long-Term Feeding Tube Placement in Elderly Patients: Decision Aid
- Making the Decision: Tube Feeding- Frequently Asked Questions
- Approach to Adult Unable to Maintain Nutrition
- Flow Chart Reference Sheet
- Checklist for Global Assessment
- Tube Feeding Worksheet
- Benefits and Burdens of PEG Placement
- Legal and Ethical Issues
Functional Assessment Tools
- Cognitive Performance Scale
- Barthel’s Index
- Prognosis in Advanced Dementia
- Geriatric Assessment Tools and Translations into Multiple Languages
- List of References
Functional Assessment Staging (FAST) Glasgow Coma Score
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