Making Choices:

Developers:
SL Mitchell MD MPH FRCPC Geriatric Medicine, Epidemiology
JM Tetroe MA Health Research
AM O’Connor RN PhD Nursing, Epidemiology
A Rostom MD FRCPC Gastroenterology, Epidemiology
C Villeneuve BSc RD Dietitian
B Hall RN BScN Geriatric Nursing

Developer disclosure:
None of the developers or their institutional affiliations can
gain financially from the information contained within this
patient decision aid.

Long Term Feeding Tube

Placement in Elderly Patients Division of Geriatric Medicine
Clinical Epidemiology Program
Ottawa Hospital – Civic Campus
Ottawa Health Research Institute
1053 Carling Ave
Ottawa Ontario K1Y 4E9
Canada

E-mail: [email protected]
SL Mitchell: [email protected]

A booklet and audio tape for substitute decision makers 2

© Mitchell, Tetroe and O’Connor 2001 (updated 2008)
 Welcome

This workbook and cassette tape have been designed to prepare

you for a decision about placing a feeding tube in an elderly
patient. As you go through the booklet and tape, you will learn
about substitute decision making as well as the advantages and
disadvantages of placing a feeding tube in your friend or family
member.

1. Set aside about 45 minutes

2. Listen to the cassette while reading

Regional Geriatric Assessment
Program
through the booklet.

3. Please stay on the page until you hear the

sound to turn to the next page.

4. Please fill out the worksheet.

Supported by a grant from Physician Services Incorporated.
Research studies that support statements in this booklet are
Dr. Mitchell is a recipient of an Ontario Ministry of Health
referenced by numbers like this: 1 . The complete list of
Career Scientist Award
references is at the back of the booklet, starting on page 37.

43
 Table of Contents This workbook is for you if:

Overview 5 • you are the substitute decision maker for an

older person who is currently unable to make
Eating and Swallowing Problems 6 his/her own health care decisions
What is a “PEG” (gastric tube)? 9
• you need to decide whether the person should have
Substitute Decision Making 13 a long term feeding tube known as a gastrostomy
tube (PEG) or a jejunostomy tube (j-tube)
Health Outcomes From Feeding Tubes 16
• this workbook does not deal with the decision
What Are My Treatment Choices? 23
to place very temporary feeding tubes called
What is Supportive Care? 24 nasogastric (NG) tubes

Can Tube Feeding Be Discontinued? 26

You will learn about:
Advantages and Disadvantages 27

How to Decide for Your Family Member: 6 Steps 28 • eating and swallowing problems
Examples of How To Decide 31
• feeding tubes
• substitute decision-making
References 37 • advantages and disadvantages of feeding tube
placement
Personal Worksheet for Feeding Tube Placement 42
• treatment options
• how to decide

5 6
 How do eating and swallowing problems
Why do people develop eating and affect older patients and those close to
swallowing problems? them?

Damage to the muscles and nerves needed for proper PHYSICAL

swallowing,
Possible causes are:
• Stroke Aspiration: Food or saliva may be inhaled into the
• Parkinson’s disease lungs if the patient is very drowsy or if he has
• Amyotrophic lateral sclerosis problems with the nerves or muscles needed to
(Lou Gehrig’s disease) swallow. This may result in lung infections.

Inability to eat independently because of: Poor nutrition: The patient will:
• Alzheimer’s disease • become weaker
• other dementias • lose weight
• become less aware of what is going on
Blockage of the esophagus (the tube that goes from • not recover as quickly from a sudden illness
the mouth to the stomach):
• cancer of the esophagus Comfort: A patient who is very aware may feel
• stricture hungry and thirsty. Patients who are not very aware
may not feel hunger or thirst.1
Severe loss of appetite or interest in eating:
major depression

7 8
 EMOTIONAL
What is a percutaneous endoscopic
Friends and family may find it difficult to accept a gastrostomy (PEG)* tube?
patient’s serious illness. They may find it hard to see
a person close to them not eat enough. They might
feel worried that the patient may feel hunger or thirst. • A tube placed directly into the stomach of
someone with eating problems

SOCIAL • An optional medical treatment

• Eating is social and symbolic of care giving. • Percutaneous – through the skin
• Helping a patient to eat can be a pleasant way to
interact with him or her • Endoscopic – a doctor will put a tube with a
• If a patient cannot be hand fed, the family may feel camera in it (an endoscope) down into the
a loss of this personal interaction. However, other patient’s stomach to help guide the tube into the
ways of socializing with him or her are always correct spot
possible.
• Gastrostomy – a procedure where a tube is put into
the stomach through a small hole in the abdomen

* Another type of long-term feeding-tube called a

jejunostomy tube may be offered to your patient. The
procedure to place this tube differs slightly. You
should ask your doctor about this.

9 10
 How is the tube put into place? How Does the person with the feeding
• The patient is mildly sedated (not put to sleep). tube get their food?
• The endoscope is placed through the mouth and
into the stomach. This can • Liquid food is put into a bag and then delivered
be a bit uncomfortable, but into the stomach through a tube.
it does not hurt. It is
needed to see where the • The food is a commercially prepared liquid that
best place is to put the tube. provides a balanced diet for the patient. It is
something like a milkshake.
• The patient is given a local
anaesthetic to freeze the • Most patients will be fed through the tube at usual
skin on the abdomen so meal times. The
that a small cut can be feeding will take about
made. The tube is inserted one hour. Some
through the mouth and patients will receive
pulled out through the continuous feedings in
opening in the abdomen. which the same
• This procedure takes about 15 amount of food is
minutes. given, but at a slower
• Sometimes it is not possible to insert the rate over 24 hours.
endoscope because the esophagus is blocked by a
growth or tumour. In these cases, the feeding tube • Medications as well as water will also be given
would be placed surgically. through the tube.

10 11
What is involved in the care of the tube? What is “substitute decision making2”?

• deciding for others who are unable to make their own

• Care must be taken not to pull out the tube. health care decisions

• The nurse will check for tube leakage, blockage • what the patient would want may not be the same as
and will make sure that the food is going in what you would choose for yourself in the same
properly. situation

• The nurse will clean around the tube at least once a • substitute decision making can be very difficult and
emotional
day and check the surrounding skin.

• The tube will usually need to be replaced within Who becomes a “substitute decision-
six months to one year. maker”?

Will the person with a gastrostomy tube

• a person previously named by the patient (someone
have to stay in bed? who has power of attorney for health care)

• next-of-kin
No, the tube is very portable. When the tube is not in
• appointed guardian
use, it will not restrict the patient’s usual activities.

12 13
 What are the steps involved in substitute Can a feeding tube be placed without the
decision making? written consent of the substitute decision-
maker?
1) Consider the previously expressed wishes of the
patient from either:
• living will (sometimes called an “advance
directive”)
• previous discussions the patient had with you
and/or others

These wishes should be respected, even if you do not

agree with them.
No
2) Consider all you know about the values of your
patient when she was well. From what you know do
you think she would choose to get a feeding tube in
this situation or not? This is called “substituted
judgement”.

3) If there are no previously expressed wishes and you

cannot judge what your patient would want, consider
what is in his “best interests”.
• what are the possible advantages of tube feeding
• what are the possible disadvantages of tube
feeding
• how will this decision affect his quality of life

14 15
 Possible health outcomes from Feeding Ranking studies about tube feeding
Tubes

In order to learn about health outcomes, you need to

Tube feeding is a medical treatment that can have a variety of understand about the different types of research studies that can
possible health outcomes or consequences. be done. There are basically three kinds:

Randomized Trials
These outcomes can be divided into two types: Gold
• whether or not someone gets a feeding tube is
• Specific complications from the feeding tube itself based on a toss of a coin
• patients with a feeding tube are comparable to
• General health outcomes that most commonly come up in patients without a feeding tube
discussions about feeding tubes, for example: • more confident in the results
(There are no randomized trials of tube feeding)
♦ survival
♦ aspiration (breathing in of food) Non-Randomized Trials
Silver
In the next few pages, we will talk about these outcomes so • patients who have chosen to have feeding tubes
that you can have a better understanding of the advantages, are compared to patients without feeding tubes
disadvantages and other considerations about tube feeding. • tube fed patients may be different from patients
without feeding tubes in ways that may affect
the outcomes
• less confident in the results

Case Series
Bronze A group of patients with feeding tubes are followed
over time to see how they do

16 17
Complications from feeding tube Will putting in a feeding tube increase the
placement patient’s chance of survival?
We have tried to summarize the studies for you so that you can
have some idea of the chances of your family member having a Gold
There are no randomized trials comparing similar
complication. The numbers below are averages (taken from
patients with and without feeding tubes to see who
articles published in medical journals) which vary from patient
lived longer. Because of this, there is no
to patient.
straightforward answer to this question of survival.
Type of Complication How many out of 100 *
patients might get it? Silver Non-randomized trials in nursing homes have found
Infections that tube fed patients do not live longer than similar
• minor (skin)3,5-10 4 out of 100 patients without feeding tubes. However, it is not clear
4,5,8,9 1 out of 100 how long these patients would have lived if they had
• major (life threatening)
never been given a feeding tube. It could be that
Bleeding
patients who are given tubes are sicker than patients
• minor (no transfusion)3,4,7 less than 1 out of 100
3,4,7 who are not given tubes.
• major (need transfusion) nearly 0 out of 100 Bronze
3,5,9,11
Temporary diarrhea, cramping 12 out of 100
Temporary vomiting, nausea3,5,11 9 out of 100 It is difficult to predict how long your patient would
Tube problems live with or without a tube. Case series of patients with
• minor (dislodgment, blockage, feeding tubes have shown that those with the following
leaking)3-9 4 out of 100 characteristics have a shorter survival:
• major (perforation of
bowel)3,4,6-8,10 less than 1 out of 100 • very old patients (over 85 years)7,10,20,23
Death • patients who tend to aspirate (breathe in) their food10
• from putting the tube in5,8,9 less than 1 out of 100 • patients who are already very undernourished 7,15
* These values are for PEG tubes only. The values may differ • patients with a previous diagnosis of malignancy 20,23,33
for jejunostomy tubes.

18 19
 How long can I expect my family member What is aspiration and how does it affect
to live? my family member?
number of patients out of 100 who will

100 • aspiration means that the patient inhales or breathes food or

90 saliva into her lungs. This happens because the patient has
trouble swallowing.
80
• it can be an uncomfortable feeling for patients to
70 experience.
60 • It can also be dangerous because it can cause pneumonia,
survive

50 an infection in the lungs.

40 Gold

30 There are no randomized trials comparing the chances

of aspiration in patients with and without feeding tubes.
20
10 Non randomized trials14,26 comparing patients with and
Silver without feeding tubes show that patients with tubes are
0
1 day 30 days 60 days 6 months 1 year more likely to be aspirators. However, it is not clear
from the studies if getting a feeding tube increases the
This chart shows you how many out of 100 elderly patients chances of aspirating, or whether being an aspirator
who have feeding tubes will still be alive in 30 days 4,5,7- increases the chances of getting a feeding tube.
9,10,12,16-25
, 60 days4,12,18,24,25, 6 months5,12,25 and 1 year Bronze
10,12,13,20,23
, after putting the tube in. The numbers on the chart It is clear from several case series23,27,28 that putting in a
are averaged over many studies. It is difficult to know for sure feeding tube will not necessarily stop a patient from
how long any one patient will live. aspirating. More than half of patients in these studies
who aspirated before they were given a tube, still
Prolonging life may or may not be what your family member aspirated after they were given a tube. On average, 16 out of
would want. This may depend on his quality of life and 100 patients with a feeding tube will aspirate3,6,7,10.
personal values or beliefs.

20 21
 What other factors are important to What are my treatment choices?
consider when deciding about placing a
feeding tube?
Because the person in your care is having eating
and/or swallowing problems, the health care team is
Stroke patients who have swallowing problems may
offering the choice of:
recover better if the feeding tube is placed earlier on
in their illness, rather than waiting a few weeks. 32

Patients who have been totally unaware of their

surroundings and dependent on others to look after supportive care
their basic needs for several months are less likely to plus
improve, whether they have a feeding tube or not. 18 placement of a feeding tube

Whether or not a patient gets a feeding tube may

determine what kind of facility he can live in. You
should discuss this with the health care team. or

Some patients with feeding tubes may become

agitated and/or may try to pull the tube out. The
health care team may suggest restraints or medications supportive care
to stop the patient from doing this. As the substitute
decision-maker, you should be involved in this
decision. This should not happen without your
consent.

22 23
 What is supportive care? Who hand feeds the patient?

• trained health care professionals (nurse, nursing

assistant or aide)
Supportive care involves:
• family, friends, volunteers
1. hand-feeding if possible
2. other treatments to keep the patient comfortable
How are patients hand-fed?
1. Hand-feeding
• proper feeding techniques are needed to help
• patients with eating problems who do not
prevent patients with eating problems from
receive a feeding tube may or may not be able
aspirating. These techniques include:
to be hand fed
• sitting her up in bed
• some patients with a feeding tube may also be
able to get some food by mouth • choosing food of the right consistency
• suctioning the mouth when necessary
How is it decided if a patient can be hand-fed? • hand-feeding a meal can take as long as two
hours
• members of the health care team (for example,
doctor, nurse, dietitian, speech and language 2. Other treatments to keep the patient comfortable
pathologist, occupational therapist) will decide • keeping the patient’s mouth moist with a
how safe it is to hand feed a patient glycerin swab or ice chips
• a special swallowing study may be done to see • pain control, with medication
what consistency of food the patient can • oxygen, for breathing problems
tolerate easily • treatment of constipation
• spiritual or emotional support
• skin care

24 25
 Can tube feeding be discontinued? What are the advantages, disadvantages
and other considerations of feeding tube
Before you decide to put in the tube, you may want to
think about what may be involved in deciding to placement?
remove the tube or stop tube-feeding at a later date.
Advantages
Technical Considerations
It is technically easy to remove the tube by: + patient may improve enough to be able to eat again
1) pulling it out using + patient gets more nutrition
traction – the tube is
designed to be
removed this way – Disadvantages
it is safe, and nearly -- complications from tube feeding, such as minor or
painless major bleeding, infections, tube problems or death
or -- may become agitated with the tube
2) cutting the tube on the outside, then using an -- feeding tube may limit where patient can receive
endoscope to remove it through the mouth. care

Possible reasons for discontinuing tube feeding

• The patient may have improved enough to be able Other Considerations
to eat normally ● will not prevent aspiration in those who are likely
OR to aspirate
• The patient may not have improved and the ● certain factors are associated with decreased
tube may no longer be in their best interests chances of survival
As a substitute decision-maker, it is your choice to ● feeding tube may or may not improve quality of life
stop tube feeding. You should discuss this decision ● Steps to making the decision
with the patients’ health care team.

26 27
 Steps To Making the Decision Z How the decision is affecting you:
i feelings of guilt
i feelings of pressure from others
n What is your family member’s situation? i conflict between your personal beliefs and
• is the underlying condition causing the eating problem
those of the patient
likely to get better?
i worry about the future decisions regarding
• is the feeding tube needed to help provide nutrition?
• how concerned are you about specific complications of continuing with the tube
the feeding tube (such as minor or major tube problems,
bleeding, infections)? [ What questions need answering before you can
• is the patient likely to become agitated with the tube decide?
and need to be restrained to keep it in?
• will feeding tube placement make a difference as to \ Who should decide about placing the tube?
where the patient can live?
• is the patient an aspirator?
• does the patient have any of the factors associated with ] What is my overall “leaning” about placing a
decreased chances of survival? feeding tube?
• how will the feeding tube affect quality of life?

o What would your family member want?

• has she ever expressed her wishes (in a living will or
previous discussion) about the use of medical
technologies like feeding tubes?
• what are his beliefs and values about end-of-life care?
• if she could weigh the advantages and disadvantages,
what do you think she would choose
• what do you feel is in your family member’s best
interests?

28 29
 Betty’s Personal Worksheet
Betty had a sudden stroke a few days ago

We have developed a worksheet to help you as you go n Your family member’s health situation
through the steps
Advantages Other Considerations Disadvantages
Over the next few pages, we will show you some
examples of substitute decision makers like you as
Improvement Survival Complication
they work through the 6 steps of making their decision unsure -under 85 small risk
about placing a feeding tube. -not malnourished Agitation
Nutrition -no malignancy unlikely
-not malnourished Facility
The examples are meant to show you how to record -hand feeding? Aspiration tube will mean move
the facts about your patient and how to weigh all of -no bedsores no to a chronic care
facility
the factors that might influence your final decision.

The examples are not meant to suggest a right or

wrong way to make the decision.
Quality of Life
-good quality of life in past 3 months
-will the tube provide an acceptable quality of
life?
-if tube will help her regain her independence,

o What would your family member want?

Patient’s feeling about feeding tube

Previous discussion-yes
ˆ ˆ ˆ ˆ ˆ ˆ ˆ
Living will - no in unsure against
favour

30 31
 Harold’s Personal Worksheet
Harold has had progressive Alzheimer’s disease for eight years.
p How is the decision affecting you?
guilt – not much pressure from others – not much
n Your family member’s health situation
conflict– not much worry about future – a lot
Advantages Other Considerations Disadvantages

Improvement Survival Complications

unlikely -over 85 unlikely
q What questions need answering before you can - very malnourished Agitation
Nutrition -no malignancy likely
decide? Facility
-very malnourished
How likely is she to recover from the stroke? If she doesn’t -hand feeding possible? Aspiration unsure if tube will
improve in the next couple of months I doubt Betty would want -has bedsores yes mean change in
to continue with the tube. Can we decide to remove it at that facility
point? How hard is it to remove?

r Who should decide about placing the tube? Quality of Life

-poor quality of life in past 3 months
Based on Betty’s previously expressed wishes, her doctor and I -unlikely that tube will provide acceptable
will decide together. quality of life to Harold
-major goal is comfort

s What is my overall “leaning” about placing a o What would your family member want?
feeding tube?
ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ Patient’s feeling about feeding
put in unsure supportive Previous discussion -no tube?
tube care only
Living will - yes ˆ ˆ ˆ ˆ ˆ ˆ 9
ˆ
in unsure against
favour

33
32 33
 Anne’s Personal Worksheet
p How is the decision affecting you? Anne had a big stroke 10 days ago. The doctor said that she may

guilt – somewhat pressure from others – not much n Your family member’s health situation
conflict– not much worry about future – not much
Advantages Other Considerations Disadvantages

Improvement Survival Complications

q What questions need answering before you unlikely -under 85 small risk
-not malnourished Agitation
can decide? Nutrition -no malignancy unsure
Will Harold feel hunger and thirst without the tube? -not malnourished Aspiration Facility
Does his nursing home accept tube-fed patients? -hand feeding? yes tube will mean move
-no bedsores from her residence
to a different facility

r Who should decide about placing the tube?

Harold hasn’t told me what to do in this situation, so I must
decide for him based on what I think he would want. I’ll talk
it over with his doctor who has known him for a long time. Quality of Life
-good quality of life in past 3 months
-it is unlikely she will return to that quality of
life, but that may not matter to Anne
-her religious beliefs are very important to her

s What is my overall “leaning” about placing a o What would your family member want?
feeding tube?
ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ9
ˆ ˆ
put in unsure supportive Patient’s feeling about feeding
tube care only Previous discussion-yes tube?

Living will - no ˆ ˆ ˆ ˆ9 ˆ ˆ ˆ
in unsure against
favour

34 35
p How is the decision affecting you?
guilt – a lot pressure from others – somewhat
conflict – a lot, I wouldn’t worry about future – somewhat
want a tube if I References
1. McCann RM, Hill WJ, Groth-Junker A. Comfort care for terminally ill
patients: the appropriate use of nutrition and hydration. JAMA
1994;272:1263-6.
q What questions need answering before you can
decide? 2. Buchanan A. Deciding for others. Milbank Quarterly 1986; 64(suppl
2):17-94.
What decision would best respect her religious beliefs?
3. Bourdel-Marchasson I, Dumas F, Pinganaud G, Emeriau J-P, Decamps
A. Audit of percutaneous endoscopic gastrostomy in long-term enteral
feeding in a nursing home. International Journal for Quality in Health
Care 1997; 9(4):297-302.

r Who should decide about placing the tube? 4. Grant JP. Percutaneous endoscopic gastrostomy. Initial placement by
single endoscopic technique and long-term follow-up. Annals of
Surgery 1993; 217(2):168-174.
I will decide after talking to the doctor and Anne’s
pastor, who knows her well. 5. Hull MA, Rawlings J, Murray FE, Filed J, McIntyre AS, Mahida YR
Hawkey CJ, Allison SP. Audit of outcome of long-term enteral
nutrition by percutaneous endoscopic gastrostomy. The Lancet 1993;
341(April 3):869-872.

6. James A, Kapur K, Hawthorne AB. Long-term outcome of

s What is my overall “leaning” about placing a percutaneous endoscopic gastrostomy feeding in patients with
feeding tube? dysphagic stroke. Age and Ageing 1998; 27:671-676.
ˆ ˆ ˆ ˆ 9
ˆ ˆ ˆ ˆ ˆ ˆ ˆ
put in unsure supportive 7. Kaw M, Sekas G. Long-term follow-up of consequences of
tube care only percutaneous endoscopic gastrostomy (PEG) tubes in nursing home
patients. Digestive Diseases and Sciences 1994; 39(4):738-743.

8. Raha S, Woodhouse K. The use of percutaneous endoscopic

gastrostomy (PEG) in 161 consecutive elderly patients. Age and
Ageing 1994; 23:162-163.

36 37
9. Sali A, Wong P-T, Read A, McQillan T, Conboy D. Percutaneous 17. Jarnagin WR, Duh QY, Mulvihill SJ, Ridge JA, Schrock TR, Way LW.
endoscopic gastrostomy: The heidelberg repatriation hospital The efficacy and limitations of percutaneous endoscopic gastrostomy.
experience. Australian and New Zealand Journal of Surgery 1993; Archives of Surgery 1992; 127:261-264.
63:545-550.

10. Light VL, Slezak FA, Porter JA, Gerson LW, McCord G. Predictive
factors for early mortality after percutaneous endoscopic gastrostomy. 18. Fay DE, Popausky M, Gruber M, Lance P. Long-term enteral feeding:
Gastrointestinal Endoscopy 1995; 42(4);330-335. a retrospective comparison of delivery via percutaneous endoscopic
gastrostomy and nasoenteric tubes. American Journal of
11. Panos MZ, Moran A, Reilly T, Wallis PJW, Wears R, Chesner IM. Gastroenterology 1991; 86:1604-1609.
Percutaneous endoscopic gastrostomy in a general hospital: prospective
evaluation of indications, outcome, and randomised comparison of two 19. Kadakia LTCSC, Sullivan HO, Starnes E. Percutaneous endoscopic
tube designs. Gut 1994; 35:1551-1556. gastrostomy or jejunostomy and the incidence of aspiration in 79
patients. The American Journal of Surgery 1992; 164(August):114-
12. Cowen ME, Simpson SL, Vettese TE. Survival estimates for patients 118.
with abnormal swallowing studies. Journal of General Internal
Medicine 1997;12(February);88-94. 20. Rabenek L, Wray NP, Petersen NJ. Long-term outcomes of patients
receiving percutaneous endoscopic gastrostomy tubes. Journal of
13. Mitchell SL, Kiely DK, Lipsitz LA. Does artificial enteral nutrition General Internal Medicine 1996; 11:287-293.
prolong the survival of institutionalized elders with chewing and
swallowing problems? Journal of Gerontology 1998; 53A(no.3):M207- 21. Samii Am, Suguitan EA. Comparison of operative gastostomy with
M213. percutaneous endoscopic gastrostomy. Mil Med 1990; 155:534-535.

14. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on 22. Stuart SP, Tiley EH, Boland JP. Feeding gastrostomy: a critical review
survival of feeding tube placement in nursing home residents with of its indications and mortality rate. Southern Medical Journal 1993;
severe cognitive impairment. Archives of Internal Medicine 1997; 86:1689-172.
157:327-332.
23. Taylor CA, Larson DE, Ballard DJ, Bergstrom LR, Silverstein MD,
15. Friedenberg F, Jensen G, Gujral N, Braitman LE, Levine GM. Serum Zinsmeister AR, DiMagno EP. Predictors of outcome after
albumin is predictive of 30-day survival after percutaneous endoscopic percutaneous endoscopic gastrostomy: A community-based study.
gastrostomy. Journal of Parenteral and Enteral Nutrition 1997; Mayo Clinic Proceedings 1992; 67:1042-1049.
21(2):72-74.
24. Tealey AR. Percutaneous endoscopic gastrostomy in the elderly.
16. Horton WL, Colwell DL, Burlon DT. Experience with percutaneous Gastroenterology Nursing 1994; February:151-157.
endoscopic gastrostomy in a community hospital. American Journal of
Gastroenterology 1991; 86:168-169.

38 39
25. Wolfsen HC, Kozarek RA, Ball TJ. Long-term survival in patients
undergoing percutaneous endoscopic gastrostomy and jejunostomy. Notes and Questions
American Journal of Gastroenterology 1990; 85:1120-1122.

26. Pick N, McDonald A, Bennett N, Litche M, Dietsche L, Legerwood R,

Spurgas R, LaForce FM. Pulmonary aspiration in a long-term care
setting: clinical and laboratory observations and an analysis of risk
factors. Journal of the American Geriatrics Society 1996; 44:764-798

27. Patel PH, Thomas E. Risk factors for pneumonia after percutaneous
endoscopic gastrostomy. Journal of Clinical Gastroenterology 1990;
12(4):389-392.

28. Finucane TE, Bynum JD. Use of tube feeding to prevent aspiration
pneumonia. The Lancet 1996;348(9039):1421-1441.

29. Wanklyn P, Cox N, Belfield P. Outcome in patients who require a

gastrostomy after stroke. Age and Ageing 1995; 24:510-514.

30. Fisman DN, Levy AR, Gifford DR, Tamblyn R. Survival after
percutaneous endoscopic gastrostomy among older residents of
Quebec. Journal of the American Geriatrics Society 1999; 47:349-353.

40 41
 Personal Worksheet for Feeding Tube Placement

1 Advantages Other Considerations Disadvantages

Factors associated with decreased survival
Conditions may improve with tube feeding Complications from the feeding tube:
Underlying condition
The patient is over 85 □ Yes □ No Minor: infection, bleeding, temporary
Undernourished □ Yes □ No diarrhea, tube problems

Previous malignancy □ Yes □ No Major: infection, bleeding, tube problems,

death
Likelihood of recovery
□ Likely □ Unlikely □ Unsure Aspiration
Feeding tube will not prevent aspiration in Agitation with the tube
Likelihood of eating again independently those who are likely to aspirate Is the patient likely to get agitated with the
□ Likely □ Unlikely □ Unsure feeding tube?
□ Likely □ Unlikely □ Unsure
May improve nutrition
Patient is very malnourished Need for special facility
□ Yes □ No Will feeding tube limit where patient can
Possibility of handfeeding receive care?
□ Yes □ No □ Maybe □ Likely □ Unlikely □ Unsure

Quality of Life

Patient’s quality of life in the last 3 months □ Good □ Fair □ Poor □ Unsure

Will feeding tube provide quality of life acceptable to patient? □ Likely □ Unlikely □ Unsure

Is feeding tube likely to prolong a poor quality of life? □ Likely □ Unlikely □ Unsure

2 What would your family member want?

Your family member has previously expressed wishes about their What do you think (based on a living will, previous discussion or your
health care? family member’s beliefs) is the patient’s overall feeling in this situation
Previous discussion □ Yes □ No about the use of medical technologies like feeding tubes?
Living will □ Yes □ No □ □ □ □ □ □ □
In Favour Unsure Against
 Personal Worksheet for Feeding Tube Placement

3 How the decision is affecting you?

Not much Somewhat A lot

Feelings of guilt □ □ □

Feelings of pressure from others □ □ □

Conflict between your personal beliefs and hose of the patients □ □ □

Worry about future decisions regarding continuing with the tube □ □ □

4 What questions need answering before you can decide?

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

5 Who should decide about placing the tube?

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

6 What is my overall “leaning” about placing the feeding tube?

□ □ □ □ □ □ □ □ □ □ □
Put in tube Unsure Supportive care only
41