5 Questions About In-Hospital Palliative Care and Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is the preferred method of feeding for patients with terminal and critical illnesses who require enteral nutrition. However, PEG may be unnecessary and avoidable among patients with a short life expectancy. Can in-hospital palliative units reduce the placement of PEG among patients with terminal illness?

To answer this, Harish Patel, MD, associate program director of gastroenterology fellowship at the BronxCare Health System, and Sridhar Chilimuri, MD, chairman of the Department of Medicine at the BronxCare Health System in Bronx, New York, and colleagues evaluated data on 780 PEGs placed in 721 patients from 2006 to 2015. The study population was divided into 2 groups, and outcomes were evaluated based on the implementation of an in-hospital palliative care unit at BronxCare Health System.

Establishment of the in-hospital palliative care unit led to a decrease for the PEG requirement among patients with dementia, as well as a significant decrease in mortality of patients who had undergone PEG after initiation to the in-hospital palliative unit.

Gastroenterology Consultant caught up with Dr Patel and Dr Chilimuri about the research, which was presented at the ACG 2019 Annual Scientific Meeting and Postgraduate Course.

GASTRO CON: What prompted you to conduct the study?

Harish Patel and Sridhar Chilimuri: Many people view gastrostomy as life-saving, and often many patients during end of life undergo the surgical procedures. Gastrostomies are often not very helpful during this time. 

GASTRO CON: What are the most important findings from the study?

HP and SC: Implementation of an in-hospital palliative care unit led to a decrease in the volume of annual gastrostomies. We also noticed that there was a decrease in 30-day mortality and overall mortality among patients who underwent PEG. Inpatient palliative care changed the practice of gastrostomy at BronxCare Health System.

GASTRO CON: What was the biggest challenge in implementing the in-hospital palliative care unit at BronxCare Health System?

HP, SC: Our hospital, just like other safety-net hospitals, is often very full. There is a constant demand for beds with overcrowded emergency rooms. So, carving out beds for palliative care is extremely challenging. Another challenge is acceptance of palliative care by African American and Hispanic populations.

GASTRO CON: How do you think an in-hospital palliative unit can benefit or improve gastrostomy practice?

HP, SC: End-of-life care often involves discussions about placement of feeding tubes. There is a misconception that feeding tubes prolong lives. Feeding tubes not only do not prolong lives but are also associated with many complications. A palliative care unit is more likely to use feeding tubes in a more appropriate manner. Many patients and families tend to avoid feeding tubes in palliative care units as opposed to patients getting usual care. Palliative care units appear to prevent routine placement of feeding tubes and, in turn, decrease complications of gastrostomies. The use of palliative consultations may provide us with more judicious use of feeding tubes among patients with a terminal illness and better outcomes.

GASTRO CON: What are the next steps of your research?

HP, SC: We want to study the feasibility of using similar end-of-life discussions regarding the use of feeding tubes in nonpalliative care units among patients who have terminal diseases. We also want to study whether nursing homes would be willing to accept patients without placements of feeding tubes.

Reference:

Patel H. The impact of in-hospital palliative unit on percutaneous gastronomy practice, volume, and outcomes [abstract 61]. Presented at: ACG 2019 Annual Scientific Meeting and Postgraduate Course; October 25-30, 2019; San Antonio, TX.