The use of tube feeding for older adults with terminal illness is growing rapidly. There are several methods, but the one most commonly used today is percutaneous endoscopic gastrostomy (PEG).¹ Unfortunately, there is very little evidence so far to show that it's use leads to improvement in the nutritional and general health status of patients, or in their 'quality-of-life'.

Spouses, close relatives and caregivers of old people with terminal illnesses really need this sort of information, to help them handle difficult questions about what is best for their loved one. "Your loved one has a fatal illness, and is not getting enough nourishment. Should we start tube feeding?" This may come from a health professional, or well-meaning friends and relatives. Often, it's the patient's close family that suggests the tube is put in. The second question comes later: "Your loved one is clearly not getting better, in fact he/she is probably experiencing severe discomfort that we can't control. Should we stop the tube feeding?"

Now some physicians in Indiana, USA, have measured the outcome in a group people treated with PEG. Although 150 people given PEG were enrolled, only 72 could be included in the analysis; the others either declined to participate or had died before the first 2-month assessment was done. A research nurse collected all the necessary information at baseline (as soon as possible after tube placement) and then every 2 months, for a year. Standard questionnaires were used to determine the subjects' functional and mental abilities, and their perceived quality of life. As over half the subjects couldn't communicate with the nurse, direct observation and input from close relatives or caregivers was also used. The patient's nutritional state was determined using body weight, skinfold thickness, the degree of hydration, and blood tests (serum albumin, creatinine and cholesterol).

The average age of the subjects was 79, and just over half of them were women. They had, for the most part, severe advanced chronic disease, and many were acutely ill on top of that. The main reason for using tube feeding was the inability to consume food and water because of: stroke (41%), Alzheimer's or another degenerative neurological disease (35%), cancer (13%), or something else (11%).

Thirty days after tube feeding was started 22% of the subjects had died, and by one year 50% had died. Comparison of the assessments made at baseline, 2 and 4 months showed that there were essentially no relevant changes in the measures made. Individual improvements were found in less than a third of the subjects in their upper and/or lower body function, and their degree of nourishment. However, over 70% of the subjects had no significant improvements over the 4-month period.

About a third of the patients had to have the PEG tube replaced at least once. Over half continued to receive food and liquids by mouth, although the main reason for placement was supposed inability to eat or drink. Most subjects reported at least one physical problem (pain, discomfort) due to the PEG.

These findings can be considered together with those from another study of PEG in patients with dementia, in which an even higher mortality rate was found.² It seems clear that tube feeding does not lengthen life in these subjects, at least to a significant extent. By the time patients are serious candidates for tube feeding, they are usually so ill that any benefits obtained are almost too small to be recognized; on the downside, PEG placement is associated with some discomfort and side effects.

There seems little justification for the increased widespread use of PEG in seriously ill older people. An editorial accompanying the article from Indiana advises physicians on how to respond when asked about tube feeding: "We do not have any information that makes us think your loved one will live longer or be more comfortable or functional if we do this procedure. We do know that if PEG is placed, there is a very high chance that he/she will die soon." Until better results are reported, this advice seems appropriate.