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Am Fam Physician. 2002;66(10):1836-1838

to the editor: Dr. Li's article, “Feeding Tubes in Patients with Severe Dementia,”1 was an excellent review of the literature on this topic. While approximately 30 percent of percutaneous endoscopic gastrostomy (PEG) tubes are placed in patients with dementia, the author elucidates that patients with dementia have poor outcomes after PEG tube placement. Feeding tubes may ease the care for some patients but, in my opinion, they also distance the patient from human contact and take away one of their last pleasurable activities. I am concerned about our increasing elderly population and the overuse of PEG tubes in populations where their use is unproven and potentially harmful.

PEG tubes were first used in 1980, with the conclusion that they would improve nutrition, promote healing, and prevent aspiration in all patients.2 Even though certain subsets of patients fare poorly with feeding tubes, I have found that few medical professionals stratify patients into different risk groups. This observation was made most clear during a chart review that I conducted with regard to spiritual history taking in chronically ill elderly patients. I reviewed the charts of 42 patients over 65 years of age who underwent PEG placement and found that almost half of them did not have an indication for the PEG and/or did not have a procedure note for the PEG in the chart. Why is PEG placement treated differently than any other surgical intervention? Why are surgeons being reimbursed for a procedure for which they do not even list an approved indication?

If placing PEG tubes in patients with advanced dementia were shown to improve quality of life, then I would recommend them in all of my patients who are malnourished or who have dementia. However, a survey of relatives of patients with PEG tubes in nursing homes in both Canada and the United States found that: (1) family members often regret having placed a PEG in their relative; (2) 60 percent did not feel it improved quality of life; and (3) 61 percent would not want a PEG for themselves in a similar situation.3

Feeding tubes are a beneficial medical intervention in select populations. Education of families, doctors, and ancillary staff about the failure of PEG tubes in elderly patients with dementia is necessary to decrease the number of unnecessary and potentially harmful procedures. As with all medical care, objective evidence rather than assumptions should guide treatment decisions regarding PEG tubes.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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