BAPEN Conference


To PEG or not to PEG? That was the question asked in the NNNG


Symposium, chaired by Liz Evans and held on the first afternoon of Conference. The purpose was to look at the pros and cons of PEGs versus naso- gastric tubes, to explore why there is pressure from nursing homes to insert PEGs, as highlighted by the report from the Royal College of Physicians published early in 2010, and discuss why there is reluctance in community care areas to use them. Consultant Gastroenterologist, Dr Sue


Cullen of Buckinghamshire Hospitals NHS Trust, took delegates back to basics to explore the pros and cons of the insertion of PEGs, which although relatively easy to insert should be viewed as a mini surgical operation. With a high mortality rate at 30 days, it is not a procedure to be undertaken lightly. Considerable ethical dimensions additionally come into play regarding decisions concerning individuals with dementia. The key indicator for the use of PEGs is that the individual can’t or won’t feed but family pressure can also be brought to bear to insert, particularly where older and frailer patients are concerned. The negative associations with PEGs are loss of the pleasure of oral nutrition and of social contact at mealtimes, and patients with dementia may pull at their tubes causing complications.


The key recommendation of the Royal College of Physicians 2010 report is that PEGs must not be inserted to save time or for any other ‘administrative’ reason. They must only be used for the benefit of the patient. A case study was presented to illustrate this clearly. Case study: A 50 year old woman with severe dementia, caused by Creutzfeldt-Jakob disease, is being cared for by her husband. She is being spoon fed and has developed a chest infection. The factors to consider are the diagnosis, ability to eat and drink, whether there is coughing and the hardest of all, the prognosis. The husband wanted the PEG as it was taking so long to feed his wife. In this case, the multi-disciplinary team decided not to place a PEG due to his wife’s poor prognosis, recommending instead more support for the husband. In concluding, Dr Cullen posed the critical question to be resolved in these difficult cases: “Are we aiming to maintain life or simply prolonging death?”


NGT pros and cons


Tracy Earley, Consultant Nurse Nutrition of Lancashire Teaching Hospitals, considered the indications for naso-gastric tubes (NGTs) – a relatively easy and safe procedure for short to medium term feeding – with poor appetite, inability to eat and the presence of GI disease indicating its use. However, there are negative aspects. They can be uncomfortable to insert, displaced or blocked and can be traumatic for patients in hospital at night when they can wake confused and be pulled out. Tracy described that in her own place of work they use the nasal bridle to secure NGTs, with 1,000 bridles used in the last four years. This enables a more secure and effective use of NGTs


5 BAPEN In Touch No.59 December 2010


in the medium term in the community and in care homes, and facilitates enteral feeding avoiding the use of PEGs. To support nursing home staff, training is provided together with a rapid access nutrition nursing service. Patients on discharge also have access to a rapid response line. Outcomes data supports this approach, with 30 day mortality down to 19% in 2009 from 25% in 2007-8. Tracy emphasised that the biggest advantage of this approach is that more patients are being fed.


Nursing homes can manage with support


The dual presentation that followed by Sue Mattinson, owner of a care/nursing home, and Neil Wilson, demonstrated a practical partnership approach to successful NGT feeding. With appropriate support at discharge for staff and patient, nursing homes can successfully manage such cases. “None of my staff had dealt with a NGT and so we looked to Neil for training and support on site,” explained Sue. “My main concerns were that our resident would aspirate, the tube might block and


that the staff had no training but I was comfortable that my staff would cope as I have a high percentage of permanent staff.” Commissioners think NGT feeding is complex, this reinforces the ‘nursing home’ view that they cannot manage. This needs to be challenged with the CQC supporting nursing homes to deliver this advanced care.


Sue concluded: “With more complex clients


now in all nursing homes, including mine, we need nurse specialists and their back-up so we can confidently deliver this type of care.” This comprehensive symposium was rounded off by a presentation by Simon Sawhney, a junior doctor in Aberdeen Royal Infirmary, who presented data analysing the reasons for, and the outcomes, of PEG placement for 102 patients; the majority placed following a stroke. Simon said: “All PEGs are not equal as each patient is unique and must be carefully assessed. Our data revealed that more than 50% of patients with dementia died within one month, making it very difficult to justify PEG tube use in dementia based on these results.”


The ‘To PEG or not to PEG’ symposium team – from left Consultant Gastroenterologist Dr Sue Cullen, Dr Simon Sawhney, Consultant Nurse Tracy Earley, Liz Evans Chair of the Symposium and of the NNNG, Senior Lecturer Neil Wilson and Care Home Manager Sue Mattinson.


Survival following PEG insertion by indication


Days post PEG Insertion


Source: Presentation by Dr Simon Sawhney @ BAPEN 2010


Proportion of Patients Surviving


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