Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

M. Gieniusz, Zucker School of Medicine at Hofstra/Northwell
L. Sinvani, Zucker School of Medicine at Hofstra/Northwell
A. Kozikowski, Zucker School of Medicine at Hofstra/Northwell
V. Patel
C. Nouryan, Zucker School of Medicine at Hofstra/Northwell
M. S. Williams
N. Kohn, Northwell Health
R. Pekmezaris, Zucker School of Medicine at Hofstra/Northwell
G. Wolf-Klein, Zucker School of Medicine at Hofstra/Northwell

Abstract

© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society Objectives: To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia. Design: Multicenter, mixed-mode, anonymous questionnaire. Setting: Three tertiary and four community hospitals in New York. Participants: Internal medicine physicians (N = 168). Measurements: Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia. Results: Ninety-nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision-making process; 38% were unsure whether the ABIM/AGSChoosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGSChoosing Wisely recommendations (71% vs 28%, P <.001). Fifty-two percent felt in control of the PEG placement decision, and 27% expressed concerns about potential litigation. The most common factor influencing physicians was patient or decision-maker request (70%); 63% stated that families request PEG placement even when physician would not recommend it. Only 4% of the physicians would choose to have a PEG tube if they had advanced dementia. Conclusion: Despite the scientific evidence supporting the ABIM/AGSChoosing Wisely recommendations against the use of PEG tubes in individuals with advanced dementia, numerous incentives for placement complicate the decision for PEG placement. In today's healthcare environment, it is incumbent upon healthcare practitioners to be aware of the available evidence and to provide leadership to guide this complex decision-making process to promote true person-centered care.