Percutaneous Endoscopic Gastrostomy in Dementia: Expectations, Outcomes, and Ethical Aspects

Percutaneous endoscopic gastrostomy (PEG) tubes are often placed as a means of feeding in older people who eat poorly, typically for those with advanced dementia. Patients with terminal dementia often lose ability to chew, swallow, and feed adequately, with failure to thrive. PEGs are often proposed as a means to maintain their nutritional needs. The decision to place a PEG involves ethical dilemmas. It has become controversial, as data demonstrate that PEGs do not improve life expectancy, quality of life, or nutritional status in dementia, nor do they reduce the tendency to aspirate or help in the healing of pressure ulcers. Often, PEGs are placed prior to full evaluation for reversible factors that account for the feeding difficulties. A multidisciplinary approach to evaluate the patient for addressable factors and alternate means of feeding should be utilized, along with a review of patient’s expressed advance directives and a meaningful discussion with the caregiver prior to the ultimate decision on feeding modality. Comfort feeding as the means of feeding should be offered as the preferred option. Undue expectations resulting from PEG should not be suggested or put forth; a reasonable understanding of the process and outcomes by the primary providers of care, gastroenterologist, other healthcare staff, and caregiver is in the best interests of the patient.