Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement

doi:10.1016/S0140-6736(96)07369-2

The Lancet

Volume 349, Issue 9050, 15 February 1997, Pages 496-498

https://doi.org/10.1016/S0140-6736(96)07369-2 Get rights and content

Summary

Guidelines for the placement of percutaneous endoscopic gastrostomy (PEG) tubes are not available. We developed a decision-making algorithm by integrating the medical and ethical dimensions of the decision. According to our algorithm, physicians should not offer PEG tubes to patients with anorexia-cachexia syndromes. For patients with permanent vegetative states, physicians should offer and recommend against the procedure. For patients who have dysphagia without other deficits in quality of life, physicians should offer and recommend the procedure. For the the remaining patients who have dysphagia with other deficits in quality of life, the physician's role is to provide non-directive counselling regarding the short and long-term consequences of a trial of PEG tube feeding.

References (20)

DE Larson et al.
Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 3 14 consecutive patients
Gastroenterology
(1987)
MA Hull et al.
Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy
Lancet
(1993)
RE Miller et al.
Percutaneous endoscopic gastrostomy. Results in 316 patients and review of literature
Surg Endosc
(1989)
WL Horton et al.
Experience with percutaneous endoscopic gastrotomy in a community hospital
Am J Gastroenterol
(1991)
SE Gibson et al.
Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients
Ann Otol Rhinol Laryngol
(1992)
RHR Park et al.
Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia
BMJ
(1992)
JP Grant
Percutaneous endoscopic gastrostomy. Initial placement by single endoscopic technique and long-term follow-up
Ann Surg
(1993)
SK Raha et al.
The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients
Age Ageing
(1994)
B Norton et al.
A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke
BMJ
(1996)
L Rabeneck et al.
Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes
J Gen Intern Med
(1996)

There are more references available in the full text version of this article.

Cited by (176)

Predicting 30-day mortality following PEG insertion: External validation of the Sheffield Gastrostomy Score and analysis for additional predictors
2021, Clinical Nutrition ESPEN
Citation Excerpt :
This is of concern as PEG placement has been associated with a significant 30-day mortality, ranging from 6 to 30% [4,5]. Given this high short-term mortality, it has been suggested that many patients receiving PEG are in the terminal stages of their disease, making the value of this long-term intervention uncertain [6]. The 2004 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, examining 30-day mortality following PEG, noted that 43% of early fatalities occurred within the first week post-PEG, and deemed 19% of procedures in the audit to have been futile [4].
and study aims: The Sheffield Gastrostomy Score (SGS) was devised to stratify patients by calculating their risk of mortality at 30 days following PEG insertion. The aim was to externally validate the SGS and identify any further predictors of 30-day mortality.
Retrospective review of all PEG insertions performed over a ten year period in our centre. All patients who had a new PEG inserted were identified and the SGS calculated. Additionally, demographic, indication for PEG insertion and other blood results were recorded. Receiver operating characteristic curves were calculated and subsequent univariate and multivariate analysis was performed to identify additional risk factors for 30 day mortality.
The PEG database comprised 1373 patients, of which 808 were suitable for analysis. For each increasing SGS gradation mortality rose, with 4% of those scoring 0 compared to 50% scoring 3. An area under the ROC curve of 0.69 (95% confidence interval 0.64–0.74) indicated good discriminative capacity. Multivariate analysis demonstrated that age ≥60 years (OR = 2.1 p = 0.016), serum albumin concentrations of 25–34 g/l (OR = 2.5 p = 0.001) or <25 g/l (OR = 6.8 p < 0.001), C-Reactive Protein ≥10 mg/l (OR = 2.7 p = 0.009) and lymphocyte count of <1.5 × 10⁹/l (OR = 2.0 p = 0.004) increased the odds of 30-day mortality, whilst referral for PEG placement whilst an inpatient decreased the risk of death (OR = 0.53 p = 0.005).
The SGS displayed reasonable predictive ability but the area under the curve is not high enough for routine clinical use. Modelling of further predictors from a multicentre study could provide scope for updating the SGS potentially improving patient selection.
Tracheostomies and PEGs: When Are They Really Indicated?
2019, Surgical Clinics of North America
Gastrointestinal feeding access — From idea to application
2019, Journal of Pediatric Surgery
Modifications in endoscopic practice for the elderly
2013, Gastrointestinal Endoscopy
To stent or not to stent: An evidence-based approach to palliative procedures at the end of life
2012, Journal of Pain and Symptom Management
Patients near the end of life often undergo invasive procedures, such as biliary stenting for obstructive jaundice, with the intent of relieving symptoms. We describe a case in which the medical team and a patient and family are considering a second palliative biliary stent despite the patient's limited life expectancy. We review available evidence to inform the decision, focusing on the specific question of whether the benefits of palliative biliary stents in patients with advanced cancer outweigh the risks. We then apply the evidence to the issue of how the primary and/or palliative care team and the interventionist communicate with patients and their families about the risks and benefits of palliative procedures. Review of the evidence found several prospective case series without control groups that measured patient-centered outcomes. Studies had high attrition rates, results for improvements in symptoms and quality of life were mixed, and rates of complications and short-term mortality were high. In conclusion, the limited evidence does not support that the benefits of palliative biliary stents in this population outweigh the risks. We propose that primary care teams consider and discuss the larger picture of the goals of care with patients and families when considering offering these procedures, as well as benefits and potential harms, and consider involving palliative care services early, before consultation with an interventionist.
Conference on diet and digestive disease bapen practitioners session: To peg or not to peg that is the question
2021, Proceedings of the Nutrition Society

View all citing articles on Scopus

View full text

Department of EthicsEthically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement

Summary

Gastroenterology

Lancet

Percutaneous endoscopic gastrostomy. Results in 316 patients and review of literature

Surg Endosc

Experience with percutaneous endoscopic gastrotomy in a community hospital

Am J Gastroenterol

Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients

Ann Otol Rhinol Laryngol

Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia

BMJ

Percutaneous endoscopic gastrostomy. Initial placement by single endoscopic technique and long-term follow-up

Ann Surg

The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients

Age Ageing

A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke

BMJ

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

J Gen Intern Med

Department of Ethics
Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement