Wednesday, April 11, 2012
End of life care: the feeding tube frenzy
Okay, readers, how many of you desire to have a feeding tube inserted into your belly one day? Some of you? A few of you? All of you? Not me, that's for sure. So, if there comes a time when I cannot speak for myself, let this blog post serve as a statement of my philosophy that I do not wish to be subjected to everything that medicine may have to offer. If I am enjoying no meaningful life, and if I am not giving pleasure to others.
I placed yet another feeding tube (PEG) in a patient this week. This is often an unsatisfying experience for me as I am not always serving the patient's interest. Usually, the patient is not capable to express his own views and the decision is properly delegated to the family or to a designated medical power of attorney (POA). In this instance the tube was medically indicated and I reviewed the procedure and the alternatives with the three daughters in a conference room.
The daughters were uncertain how to proceed. The ladies were clearly vexed. One of them was the POA. I counseled them to take more time to weigh the options. While the decision was difficult, the situation was not emergent and they had the luxury of time to deliberate. I reminded the POA that her charge was not to make a decision based on what she felt was in her mother's best interest, but to make the decision that her mom would make if she were able to do so. This distinction is critical if the patient's autonomy and medical ethics are to be respected.
Hours later, the daughters all agree to proceed with the PEG, and I did so.
Luckily, there was a consensus, as it would be very problematic to proceed if there was a split decision, even if the POA has the legal right to decide. Indeed, if this occurred, I would make every effort to facilitate a unanimous decision, and might recruit other professionals to assist in this effort. It is easy to forecast the family tensions that might ensue when there is discord on how to proceed. There are times, however, when a consensus is impossible, and the POAs directive must be followed. In such cases, at least there is a POA to make the difficult decision. When there is no POA, and the family members are torn, then the situation is delicate and difficult.
Most of the PEG tubes I place are in demented elderly individuals who reside in nursing homes. For many of them, these tubes are a rite of passage and provide a convenient portal to administer nutrition and medication. Are they truly necessary? Certainly not. Indeed, there have been numerous medical studies in recent years that conclude that individuals with advanced dementia do not benefit from feeding tubes. Moreover, the notion that feeding through PEG tubes provides comfort to patients has been challenged.
Resources are limited. If every nursing home patient had a dedicated aide who could devote the time necessary to help patients eat, then they wouldn't need a gastroenterologist like me to violate them. In addition, eating food in the conventional manner provides gustatory and social pleasures. Do we want to deprive a patient of any of life's remaining pleasures, when so few of them are remaining?
There is an aspect of the PEG procedure that does give me pleasure, and I experienced it this past week. I had placed a PEG in a rugged and vigorous man two months ago who had a temporary impairment in his swallowing function. This week, he came to my office for me to remove the tube. This is a rare event as most PEGs are placed for indefinite use.
Many hospitalized patients are advised to undergo PEGs when a swallowing study demonstrates dysfunction. My suspicion is that many of these folks have had this "dysfunction" for years, and yet have managed to get through thousands of meals over the years without loss of life. In these cases, the PEG tube can be justified, but may not be truly needed.
Obviously, many PEG tubes are absolutely necessary and should be placed. It's the rest of the PEGs that I'm lamenting over. Ask your gastroenterologist if he has ever placed an unnecessary PEG tube. If he says no, then whip out the polygraph equipment.
My advice? Make sure you have a living will with a designated medical power of attorney who will reliably act on your behalf, should the need arise. Otherwise, you might end up going down the tubes. 
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Labels: end of life, gastroenterology, guest post, MD Whistleblower, Michael Kirsch
posted by Michael Kirsch, MD at
9:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Richmond, Va., with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
interest in basic and clinical science and education, with
interests in noninvasive monitoring and diagnostic testing using
novel bedside imaging modalities, diagnostic reasoning, medical
informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication,
quality improvement, and quantitative biomedical imaging.
Informatics
Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical
Informatics & Clinical Epidemiology, Oregon Health &
Science University, posts his thoughts on various topics related to
biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.
Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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