Medical Orders for Life-Sustaining Treatment - Professionals
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 2015 with the next scheduled update in 2017.
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.
- Community-wide Clinical Guidelines on Percutaneous Endoscopic Gastrostomy (PEGs)/Tube Feeding (2015)
- Key Recommendations
- Resources for Physicians
- Approach to Adult Unable to Maintain Nutrition with Flow Chart Reference Sheet
- Checklist for Global Assessment
- Tube Feeding/PEG Placement Guide
- Benefits and Burdens of PEG Placement
- Legal and Ethical Issues
- Clinical Frailty Scale
- Cognitive Performance Scale
- Barthel’s Index
- Geriatric Assessment Tools and Translations into Multiple Languages
- Functional Assessment Staging (FAST)
- Glasgow Coma Score
- List of References
In This Section
- Advance Care Planning
- MOLST Training Center
- Frequently Asked Questions
- 8-Step MOLST Protocol
- MOLST Chart Documentation Forms for Adult Patients
- MOLST LIFE Pack
- MOLST and FHCDA Webinar Series
- EMS MOLST Training
- Resources for MOLST Trainers
- Order Free Educational Materials
- Provider Training
- MOLST Videos
- Implementation Resources
- New York State Legislation
- Ethics Review Committee
- Quality Improvement
- Capacity Determination
- 2015 MOLST Updates
- Share a MOLST Case Study
- Feeding Tubes/PEGS
- Discussion Board
- Research & References
- Resources for Patients & Families
- Conferences & Events
- Archived Educational Curriculum
- Care Transitions Intervention
- Palliative Care
- Pain Management