In pediatric gastroenterology, percutaneous endoscopic gastrostomy (PEG) tube placement is not typically a palliative measure and there is a very low mortality rate. In adult medicine, PEG tube placements are often part of palliative care and used to allow easier management in nursing homes.
A few studies this past month highlight the mortality and potential ethical dilemmas focused around PEG tube placement.
Clin Gastroenterol Hepatol 2013; 11: 1437-44. “In-hospital mortality was 10.8% among 181,196 patients who underwent PEG in 2006.”
Clin Gastroenterol Hepatol 2013; 11: 1445-50. Between 2004-2010, among 1327 patients with prospectively collected data from 2 UK hospitals, 344 (23%) did not undergo gastrostomy placement after multidisciplinary team discussion. This group had 35.5% mortality at 30 days compared with 11.2% of the 1027 who proceeded with PEG. Age >60 and low albumin were predictors of 30-day mortality.
Clin Gastroenterol Hepatol 2013; 11: 1451-52. The editorial on these two studies tries to redirect the focus from futility to quality of life in terms of PEG decision-making. “An objective scoring system to predict survival, minimize futility, and promote justice in the allocation of resources toward PEG placement is not the direction endoscopists should be taking.” If, for example, PEG tube provides palliative decompression for outlet obstruction or allows transfer to nursing home, this may align with the principle of patient autonomy. The editorial argues that if the potential goals of PEG placement can be met, this is the key factor.
Bottomline: Information on outcomes and potential futility should be discussed as part of the informed consent process. But, I bet this will not make those decisions any easier.
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