The increasing use ofpercutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eightyears of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations. the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for preand post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.
1. Simon T, Fink AS: Percutaneous endoscopic gastrostomy and jejunostomy. In Morris PJ, Wood WC (eds.): Oxford Textbook of Surgery, Vol. 1. New York: Oxford University Press, 2000, 571-572.
2.
2. Elia M, Russel CA, Stratton RJ, et al.: Trends in artificial nutritional support in the UK during 1996-2000. A report by the British Artificial Nutrition Survey, British Association of Parenteral and Enteral Nutrition. Maidenhead, UK: BAPEN, 2001
3.
3. Grant MD, Rudberg MA, Brody JA: Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998; 279(24): 1973-1976.
5. Kaw M, Sekas G: Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients. Dig Dis Sci. 1994; 39(4): 738-743.
6.
6. Callahan CM, Haag KM, Weinberger M, et al.: Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. JAm Geriatr Soc. 2000; 48(1): 1048-1054.
7.
7. Michaelsson E, NorbergA, Norberg B: Feeding methods for demented patients in end stage of life. Geriatr Nurs. 1987; 8(2): 69-73.
8.
8. Norberg A, Athlin E: Eating problems in severely demented patients: Issues and ethical dilemmas. Nurs Clin North Am. 1989; 24(3): 781-789.
9.
9. Marcus EL, Berry EM: Refusal to eat in the elderly. Nutr Rev. 1998; 56(6): 163-171.
10.
10. Cullen P, Abid F, Patel A, et al.: Eating disorders in dementia. Int J Geriatr Psychiatry. 1997; 12(5): 559-562.
11.
11. Mayeux R, Schofield PW: Alzheimer's disease. In Hazzard WR, Bierman EL, Blass JP, et al. (eds.): Principles of Geriatric Medicine and Gerontology, third ed.New York: McGraw-Hill, 1994, 1035-1050.
12.
12. Volicer L, Seltzer B, Rheaume Y, et al:: Progression of Alzheimer's type dementia in institutionalized patient: a cross-sectional study. JApplied Gerontology. 1987; 6: 83-94.
13.
13. Finucane TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999; 282(14): 1365-1370.
14.
14. McNamara EP, Kennedy NP: Tube feeding patients with advanced dementia: an ethical dilemma. Proc Nutr Soc. 2001; 60(2): 179-185.
15.
15. Skelly RH: Are we using percutaneous endoscopic gastrostomy appropriately in the elderly?Curr Opin Clin Nutr Metab Care. 2002; 5(1): 35-42.
16.
16. Garrett JM, Harris RP, Norburn JK, et al.: Life-sustaining treatments during terminal illness: who wants what?J Gen Intern Med. 1993; 8(7): 361-368.
17.
17. Gjerdingen DK, Neff JA, Wang M, et al.: Older persons' opinions about life-sustaining procedures in the face of dementia. Arch Fam Med. 1999; 8(5): 421-425.
18.
18. O'Brien LA, Grisso JA, Maislin G, et al.: Nursing home residents' preferences for life-sustaining treatment. JAMA. 1995; 274(22): 1775-1779.
19.
19. Reilly RB, Teasdale TA, McCullough LB: Projecting patients' preferences from living wills: an invalid strategy for management of dementia with life-threatening illness. JAm Geriatr Soc. 1994; 42(9): 997-1003.
20.
20. Emanuel LL, Barry M, Stoeckle J, et al.: Advanced directives for medical carea case for greater use. NEngl JMed. 1991; 324(13): 889-895.
21.
21. Carmel J, Mutran EJ: Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments. Soc Sci Med. 1999 Aug; 49(3): 303-311.
22.
22. Gerety MB, Chiodo LK, Kanten DN, et al.: Medical treatment preferences of nursing home residents: relationship to function and concordance with surrogate decision-makers. J Am Geriatr Soc. 1993; 41(9): 953-960.
23.
23. Hanson LC, Rodgman E: The use of living wills at the end of life: A national study. Arch Int Med. 1996; 156(9): 1018-1022.
24.
24. Norberg A, Hirschfeld M, Davidson B, et al.: Ethical reasoning concerning the feeding of severely demented patients: an international perspective. Nurs Ethics. 1994; 1(1): 3-13.
25.
25. Hodges MO, Tolle SW: Tube-feeding decisions in the elderly. Clin Geriatr Med. 1994; 10(3): 475-488.
26.
26. Hasan M, Meara RJ, Bhowmick BK, et al.: Percutaneous endoscopic gastrostomy in geriatric patients: attitudes of health care professionals. Gerontology. 1995; 41(6): 326-331.
27.
27. Mebane E, Oman R, Kroonen L, et al.: The influence of physician race, age, and gender on physician attitude toward care directives and preference for end-of-life decision making. JAm Geriatr Soc. 1999; 47(5): 579-591.
28.
28. Lindemann B, Nikloaus T: Outcomes of percutaneous endoscopic gastrostomy in dementia patients. JAm Geriatr Soc. 2001; 49(6): 838-839.
29.
29. Finucane TE, Christmas C: More caution about tube feeding. J Am Geriatr Soc. 2000; 48(9): 1167-1168.
30.
30. Moller P, Lindberg CG, Zilling T: Gastrostomy by various techniques: evaluation of indications, outcome and complications. Scand JGastroenterol. 1999; 34(10): 1050-1054.
31.
31. Grant JP: Percutaneous endoscopic gastrostomy. Initial placement by single endoscopic technique and long-term follow-up. Ann Surg. 1993; 217(2): 168-174.
32.
32. Kohli H, Bloch R: Percutaneous endoscopic gastrostomy: a community hospital experience. Am Surg. 1995; 61(3): 191-194.
33.
33. Light VL, Slezak FA, Porter JA, et al.: Predictive factors for the early mortality after percutaneous endoscopic gastrostomy. Gastrointest Endosc. 1995; 42(4): 330-335.
34.
34. Thompson MP, Morris LK: Unexplained weight loss in the ambulatory elderly. JAm Geriatr Soc. 1991; 39(5): 497-500.
35.
35. Morley JE, Kraenzle D: Causes of weight loss in a community nursing home. JAm Geriatr Soc. 1994; 42(6): 583-585.
36.
36. Schreiber S, Lerer B: "Failure to thrive" in elderly depressed patients: a new concept of a different name to an old problem?Isr J Psychiatry Relat Sci. 1997; 34(2): 108-114.
37.
37. Morley JE: Anorexia of aging: physiologic and pathologic. Am J Clin Nutr1997; 66: 760-763.
38.
38. Nelson FL, Farberow NL: The development of an Indirect Self-Destructive Behaviour Scale for use with chronically ill medical patients. Int JSoc Psychiatry. 1982; 28(1): 5-14.
39.
39. Nelson FL, Farberow NL: Indirect self-destructive behavior in 29 the elderly nursing home patient. JGerontol. 1980; 35(6): 949-957.
40.
40. Carr-Lopez SM, Phillips SL: The role of medications in geriatric failure to thrive. Drugs Aging. 1996; 9(4): 221-225.
41.
41. Johnson JC, Kerse NM, Gottlieb G. et al.: Prospective versus retrospective methods of identifying patients with delirium. J Am Geriatr Soc. 1992; 40(4): 316-319.
42.
42. Amann W, Mischinger HJ, Berger A, et al.: Percutaneous endoscopic gastrostomy: 8 years of clinical experience in 232 patients. SurgEndosc. 1997; 11(7): 741-744.
43.
43. McGillivray T, Marland GR: Assisting demented patients with feeding: problems in the ward environment: A review of the literature. JAdv Nurs. 1999; 29(3): 608-614.
44.
44. Leclerc CM, Wells DL: Use of a content methodology process to enhance feeding abilities threatened by ideational apraxia in people with Alzheimer's-type dementia. Geriatr Nurs. 1998; 19(5): 261-268.
45.
45. Littlewood S, Saedi S, Williams C: Mealtimes: a missed opportunity. JDementia Care. 1997; 5: 18-19.
46.
46. Mairis E: An appetite for life: assessing and meeting nutritional needs. Prof Nurse. 1992; 7(11): 732-734, 736-737.
47.
47. Barnes KE: An examination of nurses' feelings about patients with specific feeding needs. JAdvNurs. 1990; 15(6): 703-711.
48.
48. Goldsmith M: Slow down and listen to their voice. JDementia .Care. 1997; 4: 24-25.
49.
49. Deutekom EJ, Philipsen H, Ten Hoor F, et al.: Plate waste producing situations on nursing wards. Int JNurs Stud. 1991; 28(2): 163-164.
50.
50. Norberg A, Backstrom A, Athlin E, et al.: Food refusal amongst nursing home patients as conceptualized by nurses aides and enrolled nurses: an interview study. JAdv Nurs. 1988; 13(4): 478-483.
51.
51. Andresen G: Caring for People with Alzheimer 's Disease: A Training Manual for Direct Care Providers. Baltimore: Health Professions Press, 1995.
52.
52. Durnbaugh T, Haley B, Roberts S: Assessing problem feeding behaviors in mid-stage Alzheimer's disease. Geriatric Nurs. 1996; 17(2): 63-67.
53.
53. Gillick MR: Rethinking the role of tube feeding in patients with advanced dementia. NEngl JMed. 2000; 342(3): 206-210.
54.
54. Weir RF, Gostin L: Decisions to abate life-sustaining treatment for non-autonomous patients: ethical standards and legal liability for physicians after Cruzan. JAMA. 1990; 264(14): 1846-1853.
55.
55. Lynn J, Childress J: Must patients always be given food and water? In Lynn J, (ed.): By No Extraordinary Means. Bloomington, IN: Indiana University Press, 1986, 47-60.
56.
56. Steinbrook R, Lo B: Artificial feeding solid ground, not slippery slope. NEngl JMed. 1988; 318(5): 286-290.
57.
57. Omnibus Budget Reconciliation Act of 1987. Medicare and Medicaid requirements of long-term care facilities. 42 CFT. Part 483.
58.
58. Fainsinger RL, Bruera E: When to treat dehydration in a terminally ill patient?Support Care Cancer. 1997; 5(3): 205-211.
59.
59. Siegler M, Weisbard AJ: Against the emerging stream. Should fluids and nutritional support be discontinued?Arch Intern Med. 1985; 145(1): 129-131.
60.
60. National Conference of Catholic Bishops. Ethical and religious directives for Catholic health care services. Washington, DC: US Catholic Conference, 1995.
61.
61. Rosin AJ, Sonnenblick M: Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation. J Med Ethics. 1998; 24(1): 44-48.
62.
62. Finucane TE, Bynum JP: Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996; 348(9039): 1421-1424. [Erratum in Lancet. 1997; 349(9048): 364.]
63.
63. Peck A, Cohen CE, Mulvihill MN: Long-term enteral feeding of aged demented nursing home patients. JAm Geriatr Soc. 1990; 38(11): 1195-1198.
64.
64. Evans LK, Strumpf NE: Tying down the elderly. A review of the literature on physical restraint. JAm Geriatr Soc. 1989; 37(1): 65-74.
65.
65. Mitchell SL, Kiely DK, Lipsitz LA: The risk factors and impact on survival of feeding tube replacement in nursing home residents with severe cognitive impairment. Arch Int Med. 1997; 157(3): 327-332.
