Barriers to limiting the practice of feeding tube placement in advanced dementia

Abstract

Objective: In advanced dementia, many difficult decisions may arise as the disease progresses, including whether to use feeding by tube. Several recent articles question the benefit of percutaneous endoscopic gastrostomy (PEG) tube placement in persons with advanced dementia. However, patients with advanced dementia are still referred for PEG tubes. This study attempts to understand more about physician decisions to recommend PEG tube placement in patients with advanced dementia.

Design: Mailed survey.

Setting: Random sample of 500 physicians from the American Medical Association Masterfile.

Participants: Primary care physicians.

Measurements: Physician knowledge, beliefs, and self-reported practices of PEG tubes in advanced dementia.

Results: Of the 416 eligible participants, 195 completed surveys (response rate of 46.9%). A significant number of physicians believe PEG tubes have the following benefits in advanced dementia: reduce aspiration pneumonia (76.4%), and improve pressure ulcer healing (74.6%), survival (61.4%), nutritional status (93.7%), and functional status (27.1%). Most physicians underestimate 30-day mortality in patients who receive a PEG and more than half of physicians believe PEG tubes in advanced dementia are the standard of care. Also, a majority of physicians believe speech therapists, nurses, and nutritional support teams recommend feeding tubes, which influences their decision to recommend a PEG. Last, almost half of these respondents had a nursing home request PEG tube placement, leading physicians to recommend a PEG.

Conclusions: We find a notable discord between physician opinion, reported practice, and the literature regarding PEG tubes in advanced dementia that reveals some of the barriers to decreasing the referral of these patients for PEG.