Is enteral tube feeding using PEG really beneficial?

Summarized by Robert W. Griffith, MD
October 9, 2000 (Reviewed: February 1, 2003)

Introduction

The use of tube feeding for older adults with terminal illness is growing rapidly. As we have discussed elsewhere in this site - see Tube feeding in malnutrition - several methods are available. The one most commonly used today is percutaneous endoscopic gastrostomy (PEG). PEG can be used safely in severely and chronically ill old people, but there is little evidence to date that it's use is accompanied by improved functional, nutritional or subjective health status. Dr Callahan and colleagues of Indiana, USA, have recently measured the relevant outcomes among a cohort of patients treated with PEG.

Method

All patients aged 60 and above receiving PEG from one of four gastroenterology practices in a 60,000-person community over a 14-month period were assessed. There were 150 subjects at baseline, who were followed for a one-year period. As soon as possible after the PEG procedure a research nurse obtained informed consent for the survey, demographic data, the indication for PEG, and any necessary clinical information. Then every two months the nurse obtained subjective data using standardized questionnaires to assess functional and cognitive status, and health-related quality of life.¹ The nurse visited the patient at hospital, nursing home or residence, in order to make these assessments.

The nurse's observations of performance, or reports from caregivers or medical records, were used to determine activities of daily living (ADL) and instrumental activities of daily living (IADL) scores, as well as upper and lower body function scales. Nutritional status was assessed using body mass index (BMI), skinfold thickness, serum albumin and serum cholesterol. The serum BUN:creatinine ratio gave an indication of hydration. Patients and their caregivers were asked to report any problems connected with the PEG tube, and how often the tube had been replaced.

Using all available records, the nurse calculated the Cumulative Illness Rating Scale for geriatric patients (CIRS-G) and the APACHE III score as a measure of acute illness.

Results

The man age of the subjects at baseline was 78.9 years, and 56% were women. Their mean CIRS-G score was high (24.3), indicating a heavy burden of chronic disease. APACHE III scores showed a moderate to high severity of acute illness.

Indications for PEG placement were stroke (41%), neuro-degenerative disorder (35%), cancer (13%), and other (11%). Of the 150 patients enrolled, 27 declined to participate, and 24 died before the baseline assessment was completed, leaving 99 for evaluation of outcomes. (Of these, 27 died, had PEG removed, or declined to participate further, before the first 2-month assessment.)

The 99 subjects who completed baseline assessment showed severe physical and cognitive impairment, and most of them were also acutely ill at the time of PEG. The mean ADL scores were 5.7 impairments (out of 6), and 60% could not communicate verbally; those that could were unable to provide useful subjective information because of severe cognitive impairment. Their 30-day mortality was 22%, and the 12-month mortality 50%.

In the 72 subjects who completed the 2-month assessment, an attempt was made to determine the extent of change in various parameters over the first 4 months after PEG. (For those that died between 2 and 4 months, the 2-month data were used.) There were essentially no changes in mean values for the majority of the 19 parameters evaluated. To count as an individual improvement - or worsening - the 4-month value had to have changed by at least one standard deviation over baseline value. By this criterion, a minority of patients (<30%) experienced improvements in upper and lower body function, serum albumin, and hydration. It was not possible to demonstrate any difference in response to PEG depending on the indication for the procedure. Over 70% of the subjects experienced no significant improvements over the 4-month period.

About a third of the patients required at least one PEG tube replacement. Over half continued to receive food, liquids and/or medications by mouth. Most subjects reported at least one physical symptom related to the PEG.

Comment

What are the implications of this study? Tube feeding and parenteral nutrition have been identified as being among the most controversial medical advances. The ethical and legal decisions that have to be taken about withholding or withdrawal of tube feeding may have pushed the relevant clinical findings into the background. The results of this and other studies may make such decisions easier.

The findings here can be considered together with those from another study of PEG in patients with dementia, in which a slightly higher mortality rate was found.² Should one advise for or against the use of PEG in seriously ill older patients? An accompanying editorial, after assessing the data from Callahan and colleagues, expresses a useful response to difficult questions: "We do not have any information that makes us think your loved one will live longer or be more comfortable or functional if we do this procedure. We do know that if PEG is placed, there is a very high chance that he/she will die soon."

Source

• Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. CM. Callahan, KM. Haag, M.  Weinberger,  et al., J Am Geriatr Soc, 2000, vol. 48, pp. 1048--1054

Footnotes
1. Subjective ratings included self-rated health, daily pain on a 10-point visual-analogue scale, the Life Satisfaction Index, the Mini-Mental Status Examination and the Geriatric Depression Scale.
2. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. DS. Sanders, MJ. Carter, J. D'Silva,  et al., Am J Gastroenterol, 2000, vol. 95, pp. 1472--1475

Related Links
Clinical Aspects of Long-Term Enteral Nutrition Via Percutaneous Endoscopic Gastrostomy (PEG)

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