Percutaneous endoscopic gastrostomy in cognitively impaired older adults: A geropsychiatric perspective

Abstract

The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.

How are Treatment Decisions Made about Artificial Nutrition for Individuals at Risk of Lacking Capacity? A Systematic Literature Review

“…However, changes in a patient’s condition were often the primary triggers for beginning the decision-making process [35]–[49]. For all three groups, weight loss [38]–[40], [47], observed changes in nutritional status [35], [38], [42], [44], [45], [50], [51], swallowing difficulties [38], [42], [45], [47], [48], other difficulties with feeding [40], [47], and food refusal [52]–[55], were sources of concern and prompted initial discussions.…”

“…Many studies across North America and Europe cited the pleasure of eating as the main reason behind forgoing tube feeding in palliative contexts [47], [68], [77] and for younger people with intellectual disabilities [37], [69]. For parents of children with intellectual disabilities, oral feeding had a special significance; it was seen as “playful” “together time” for parent and child [37].…”

“…However, verbal wishes expressed once a person’s disease had progressed were sometimes considered untrustworthy [54].Within studies of dementia and ABI, non-verbal signals, such as pushing food away, were frequently incorporated into an assessment of presumed wishes [35], [36], [47], [48], [52], [66], [68], [87]. Some even felt this was an expression of patient’s right to autonomy and should be decisively respected [67].…”

“…Some even felt this was an expression of patient’s right to autonomy and should be decisively respected [67]. A smaller number of participants viewed such behaviour as a symptom of disease and advocated forced feeding or artificial feeding [38], [47], [54], [68]. In contrast, within studies of children with intellectual disabilities, non-verbal signals were not weighted with the same importance in the decision-making process [37], [39], [69].…”

“…When family members were able to influence decisions, the style used was either: ‘best interests’, often only taking into account the patient’s physical condition [41], [47], [78], [80], [92], or ‘substituted judgment’ in which the surrogate made decisions based upon the patient’s presumed wishes [66], [84], [88], [92]. A smaller number of surrogates made reference to ‘what they would want for themselves’ [84], [88].…”