Thursday, June 16, 2011
A near miss 'never event': A truly futile PEG tube
I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don't. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great ... won't starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn't benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient. 
The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.
An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician's custom, I asked the nurse to summarize the patient's hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these trach tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a trach tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.
While this scenario never achieved "never event" status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn't enter the patient's room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn't eating well? One can imagine how a never event can happen, especially if necessary safeguards and checks are bypassed or ignored.
I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn't happen in this case. 
This post by Michael Kirsch, 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: gastroenterology, guest post, hospital medicine, MD Whistleblower, Michael Kirsch, patient safety
posted by Michael Kirsch, MD at
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2 Comments:
I'm finishing my first year of residency. At my current hospital a consulting gastroenterologist or other specialist would always discuss the case with residents and/or ICU attending before placing a PEG tube or performing any procedure.
We never rely solely on paper or computerized order trails for procedures or even for most consultations. This helps the physicians function better as part of a healthcare team rather than in parallel universes and the end result is better care for patients.
Your post implies to me that a tube could be erroneously inserted in a demented patient unable to speak for herself. I find this difficult to imagine given required procedural consent from the patient or health care proxy. Do policies differ at some hospitals?
One of the costs of technology and EMR is it reduces direct communication between physicians and between physicians and nurses. There is still no substitute for a human to human conversation between members of the health care team. This has created new potentials for clinical errors. We must remain mindful of this and remain vigilant and carefu.
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