Newsletter :: May 2004

DiagnosTEX – we want to be your provider of choice

You will never hear “we will be in Dallas at the end of the week”. You will never hear “we do not work on Fridays”. DiagnosTEX is available to the DFW area 5 days a week and will do your study within 24- 48 hours! You get more than just an MBSS you get a Dysphagia consultation. SLP’s deserve to have a choice. Give us one try and you will see a difference in our reports, staff, and the MBSS, guaranteed! We will beat any rate in DFW.

Dysphagia Tidbit – Percutaneous Endoscopic Gastrostomy – PEG

Scrutinizing the Issues of Tube Feeding in the Dementia Population – references from Sean Swint article

Since the development approximately 25 years ago by Ponsky and Gauderer at the babies and Children’s Hospital in Cleveland, Percutaneous Endoscopic Gastrostomy (PEG) have become widely used. Today the PEG tubes are frequently placed in adults with head and neck CA, neurological diseases with dysphagia and patients who are unresponsive. The one area of controversy is their overzealous use. Most clinicians are compassionate and try to do whatever possible to help their patients. A PEG is a surgical procedure for placing a feeding tube without performing an open operation on the abdomen. Local anesthesia is used to anesthetize the throat. An endoscope is passed through the mouth, throat, and esophagus to the stomach. The doctor then makes a small incision in the skin of the abdomen and pushes an intravenous cannula through the skin into the stomach and sutures it in place. Possible complications include wound infection, and dislodging or malfunctioning of the tube. A PEG takes less time, carries less risk, and cost less than a classic surgical gastrostomy. It can be performed in 15-30 minutes and is successful in over 95% of patients (Gauderer MWL et al, 1981, 1985). A PEG should not be used for nutritional support when a gastrointestinal tract obstruction is present. Patients with GERD can have a modified PEG technique the Endoscopic Percutaneous Jejunostomy (J-tube). The purpose is to provide fluids and nutrition directly to the stomach. It is placed by a doctor in a hospital or outpatient setting.

One of the most agonizing decisions a person may ever have to face is what to do when a loved one is dying. Should a feeding tube be used when a demented patient can not eat on their own? Muriel R. Gillick, MD wrote an article addressing this issue and highlighted that the inability to eat signals the end stage of the disease, and the thought process should be hospice. The knee jerk approach is that if someone stops eating to place a feeding tube. 1995 figures showed 121,000 patients received gastrostomy tubes, and about 30% of these have dementia. A 1997 study found no difference in survival rates between nursing home patients with advanced dementia fed by hand and those fed by feeding tubes. Nevertheless these studies are observational and Gillick states that certain subgroups, such a persons with vascular dementia who have dysphagia because of a small brain stem stroke or other might benefit from tube feeding. Frena Gray-Davidson, a self described Alzheimer educator speaks about what she calls the body’s decision: that by refusing to eat, the body is making an organic choice to die and a turn off point where the body fades into death. Legal and regulatory measures that act as barriers to removal of tube feeding in patients with advanced dementia would be nullified if it were viewed as a terminal illness. But talking to those loved ones and caregivers the decision is not so cut and dry. Two cases reviewed in the article both agree they would put a feeding tube in again. Gary Barg, the publisher of Today’s Caregiver Magazine, who has a grandfather in late stage Alzheimer’s, says that his family decided to have the feeding tube. Another who has gone through it, Sue Rosen made the decision to put her mother on a feeding tube, who survived almost 10 years dying at 95. Her brother who was a doctor helped make the decision easy and are glad they did it. Anne Serra her relative still has life left in her and resisted the feeding tube trying to pull it out but an amazing thing happened she began eating again and we were able to take the tube out and she was good for another year. All of these people agreed on the same thing, that the time to talk about a person’s expectations should they get sick is before the illness sets in or before it gets too bad. Gray Davidson says “very often what she sees is a collection of misunderstandings, accidents, staff negligence, and a little medical this and that, and it is a whole picture of various things going on. On a whole she thinks this group of people should not be tube fed but she does not tell families this. She leads them though the whole issues looking at the process and acceptance of the disease and death and making the decision they will live with. She says “my personal bias is not tube feeding, but up until then, have as good a life you possibly can with Alzheimer’s. This is family and patient decision

For additional literature on PEG, give us a call we will fax it to you.