For physicians, inserting a percutaneous endoscopic gastrostomy (PEG) tube is a routine procedure. However, for the families of ailing seniors, it raises disturbing questions and fears about life and death. PEG tubes, used for long-term nutritional needs, can be lifesaving when used appropriately. Yet, the widespread use of these tubes among dying, elderly patients has sparked controversy.
PEG Tubes: A Lifesaving Tool or a Futile Procedure?
The use of PEG tubes is well-accepted for patients with long-term nutritional needs and good recovery prospects. However, controversy arises when these tubes are used in elderly patients with terminal illnesses.
Critics argue that this practice often does more harm than good. Dr. David Weissman, a palliative care physician, emphasizes that PEG tube insertion is not a benign procedure. It carries risks such as uncontrolled bleeding, infection, and inflammation.
Even when the surgery goes smoothly, the tubes can diminish patients’ quality of life, causing emotional distress and adversely affecting their sense of dignity.
Economic Incentives Behind PEG Tubes
The medical industry benefits from the routine use of PEG tubes. Hospitals, nursing homes, and medical technology companies profit from these procedures. The cost of inserting a PEG tube is around $3,000, making it a significant revenue stream for these institutions.
The financial incentives can sometimes overshadow the patient’s best interests, leading to the unnecessary use of PEG tubes in elderly patients.
Historical Context and Rise in Use
PEG tubes were introduced in the 1980s to provide nutrition for children and young adults unable to eat. Their use has since expanded to the elderly population. In 1988, around 60,000 PEG tubes were used on patients aged 65 and older.
By 2010, this number had increased to 188,000. In Iowa, PEG procedures rose from 1,032 in 1997 to 1,365 in 2008. This significant rise reflects the broader trend of increased PEG tube use among elderly patients.
The Tube-Feeding Death Spiral
Critics describe a typical scenario where a patient nearing the end of a fatal chronic illness is admitted to the hospital. Medical staff observe swallowing difficulties, leading to a recommendation for non-oral feeding.
The feeding tube often provokes agitation, requiring physical restraints. This can lead to complications such as pneumonia, resulting in a cycle of repeated interventions and ultimately, the patient’s death.
The American Gastroenterological Association’s Recommendations
The American Gastroenterological Association recommends PEG tubes for patients who cannot eat and require long-term feeding. However, there is no proof that PEG tubes enhance the length or quality of life for patients with advanced neurological diseases.
The association states that patients who undergo the surgery must have functioning digestion and be able to tolerate the operation. Yet, for people with conditions like Alzheimer’s, even if they meet these qualifications, they are unlikely to benefit from a PEG.
Ethical and Practical Concerns
Dr. John Rachow, a geriatrics specialist, argues that PEG tubes do not reverse the dying process for those nearing life’s end. Inserting a feeding tube at this stage is often pointless and can be harmful. Elderly patients may be confused and distressed by the tube, and physical restraints may be necessary to prevent them from pulling it out.
Confused elderly patients may be alarmed to find a tube protruding from their stomach, Weissman said; some have to be physically restrained so they won’t pull the tube out. Furthermore, PEG tubes don’t always ward off the problems they are supposed to prevent – such as keeping patients with advanced dementia from getting aspiration pneumonia.
“Putting in a feeding tube does nothing to prevent aspiration,” Weissman said.
This is because people who can’t swallow still may inhale their own saliva or gastric juices from the stomach into the lungs, which is no less dangerous than breathing in food and drink.
Making the Feeding Tube Decision
At the University of Iowa’s hospital, the decision to insert a PEG tube is made quickly. If a patient’s ability to eat has not improved within 48 to 72 hours, the healthcare team considers alternative feeding strategies.
Dr. Justin Smock emphasizes the importance of nutrition for recovery, but also acknowledges the ethical dilemmas involved. In considering whether to place a PEG tube, the possibility that eating by mouth might lead to a patient’s death weighs heavily on the minds of physicians.
Doctors may order a swallow test, overseen by a speech pathologist. Mild swallowing problems might call for simply a change in diet, while severe swallowing problems may result in a feeding tube, which requires a doctor’s order and the patient or family’s consent.
“Once we know the patient needs a PEG tube, the hospital is pretty good about getting them in,” said Molly Klokkenga, a social worker in the UI Hospital neurology unit. “If physical or occupational therapy says they need skilled [care] and they’re having difficulty swallowing, then we’ll just go ahead and do a PEG tube.”
Smock said swallow studies “almost always confirm what you know,” and geriatrician Rachow agreed. However, he cautioned against relying on swallow tests when abnormal swallowing may be a temporary condition apart from underlying chronic problems.
“There’s a flaw in the logic that a swallowing test during acute illness really tells you what they had before they got sick,” he said.
In Rachow’s view, the swallow test can become a means for physicians to justify insertion of a PEG tube in a context of intense anxiety. Patients and their families typically face great uncertainty about the kind of care that will follow a hospital stay, and by placing a PEG, doctors help relieve their anxieties, he said.
The Role of Swallow Tests
Swallow tests, overseen by speech pathologists, are used to determine the need for a PEG tube. However, Dr. Rachow cautions against relying on these tests during acute illness, as they may not reflect the patient’s usual swallowing ability. The tests can become a means for physicians to justify PEG tube insertion amidst intense anxiety about post-hospital care.
Rachow wishes more physicians would call him before their patients go to nursing homes, but most do not: He said he hears from doctors in about one out of five cases. Medical residents who often handle discharges are especially busy, he noted.
“A lot of pressure is on them to move the patient through. The young doctor in internship, buried in work, just can’t see that there is another world of care going on outside the hospital.”
Challenges in Nursing Homes
Dr. Rachow, as attending physician for numerous nursing homes in southeast Iowa, has witnessed an increase over the past decade in the number of patients coming to nursing homes with a PEG tube in place after short hospital stays, even when a long-term feeding device seems unwarranted.
The more it’s done, the more it just becomes the standard. This trend is concerning because it may lead to unnecessary procedures and increased suffering for patients who do not benefit from the PEG tube.
Conclusion
The routine use of PEG tubes in elderly patients with terminal illnesses raises significant ethical and practical concerns. While PEG tubes have important uses, their application in dying patients often does more harm than good.
A more thoughtful, patient-centered approach to end-of-life care is needed to ensure that medical interventions align with the best interests of the patient.
