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Medicine » Otorhinolaryngology » "Seminars in Dysphagia", book edited by Renee Speyer and Hans Bogaardt, ISBN 978-953-51-2151-0, Published: September 2, 2015 under CC BY 3.0 license. © The Author(s).

Chapter 8

Decision Making for Enteral Nutrition in Adult Patients with Dysphagia – A Guide for Health Care Professionals

By Nicoll Kenny and Shajila A. Singh
DOI: 10.5772/60987

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Decision Making for Enteral Nutrition in Adult Patients with Dysphagia – A Guide for Health Care Professionals

Nicoll Kenny1 and Shajila A. Singh2

1. Introduction

A review of current literature reveals high mortality rates post insertion of feeding tubes for the provision of long term enteral nutrition, most specifically post placement of a percutaneous endoscopic gastrostomy (PEG). The recommendation of enteral nutrition is often a complex decision, which requires the consideration of many aspects, including not only the medical need for nutritional support, but also the wishes of the patient and their families. The provision of artificial nutrition and hydration can be an emotional topic which leaves many health care professionals uncomfortable and unsure of what recommendations to make. This chapter aims to provide information about the different methods of enteral nutrition available and the indication for each one. It also hopes to present a number of factors that need to be considered by all health care professionals who are involved in the recommendation of enteral nutrition.

Enteral nutrition is the provision of sustenance into the stomach or small intestine and includes tube feedings as well as oral nutritional supplements [1]. The focus here is on enteral nutrition via tube feeding.

2. Indications for enteral nutrition

Optimal hydration and nutrition is required to meet the body’s daily nutritional requirements. Patients with dysphagia may be unable to attain these minimum nutritional requirements with oral intake and require enteral nutrition [2-9]. These patients include those who are unable to swallow due to neurological damage or degeneration [4, 10-15], or those who have structural abnormalities that make oral nutrition impossible, as in the case of patients with advanced stage head and neck cancer or oesophageal cancer [16-18].

The most common indicator for long term enteral nutrition is a cerebral vascular accident (CVA) [3, 5, 10-12, 19-26]. Dysphagia with resulting malnutrition and/or dehydration is common in patients who have had a CVA, explaining the high need for enteral nutrition within this population [10, 13, 27-28]. Patients with other neurological deficits such as traumatic head injury or neuro-degenerative diseases, may also require short or long term enteral nutrition as a safe method of hydration and nutrition [7, 29-33].

Certain medical conditions are more likely to predispose patients to require enteral nutrition because of concomitant dysphagia and increased nutritional needs. Patients with head and neck cancer may develop dysphagia after radiation treatment as a result of tissue damage to the swallow mechanism [18] with a resultant need for prophylactic enteral nutrition [17]. Those patients who continue on oral intake may require enteral nutrition as a supplement to ensure sufficient intake of the daily nutritional requirements while receiving radiotherapy [18]. In cases of trauma to the body or after surgery, enteral nutrition is also recommended to aid sufficient caloric intake to minimise loss of body fat and to support recovery [15, 29, 31-32, 34-35].

3. Enteral nutrition routes

There are different enteral nutrition routes, and the route chosen is determined according to the length of time and the type of enteral support needed for a specific patient. The different types of enteral nutrition include nasogastric tubes (NGTs) and nasojejenal tubes (NJTs); surgically placed gastrostomy tubes (GTs) and jejenostomy tubes (JTs); and non-surgical placement methods include percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejenostomy (PEJ).

Before the development of the PEG procedure by Gauderer and Ponsky in the early 1980s, a gastrostomy tube was placed under general anaesthetic. PEG has become the most popular method of tube placement because of the ease of insertion, minimal invasiveness and no requirement for a general anaesthetic [36-38]. A surgical gastrostomy may still be performed in cases where PEG is not possible due to obstruction which makes the passing of the scope down the gastrointestinal tract impossible [39].

4. Short term versus long-term enteral nutrition

The placement of NGTs are recommended for the delivery of early enteral nutrition in the acute stages of disease [2, 10, 13, 40]. The benefits of early enteral nutritional have been documented within various groups of patients [41-44]. NGTs are for short term use only and should not be in situ for periods longer than 4 to 6 weeks [2, 15], as they can cause serious complications including nasal ulceration, chronic sinusitis and increased risk of aspiration pneumonia [15, 39, 45].

NGTs are easy to insert and require no surgical procedure or administration of anaesthetics for placement [10, 14, 46]. However they are poorly tolerated by patients, and are often pulled out after insertion thereby reducing the nutritional advantage which was the aim of placement [47-49]. NGTs may be placed incorrectly by the professional inserting them, with incidences reported to range from 0.3 to 27% (cited by [50] in [51]). A misplaced NGT may result in aspiration pneumonia which can be fatal [51]. Patient positioning, with most hospitalized patients being in a sedated state or lying flat, during NGT feeding can also result in aspiration pneumonia [52-53]. An increase in reflux with NGT placement has been noted [39, 46] particularly in cases with pre-existing gastro-oesophageal reflux [54]. Similar negative effects have been noted with the use of PEGs [46].

If a patient requires enteral nutrition for a period longer than 4 to 6 weeks, and the prognosis justifies the intervention, placement of a gastrostomy or PEG tube for the provision of long term enteral nutrition could be considered [14, 19, 55, 56]. However, Maitines et al. (2009) suggest a longer period of at least 6 to 8 weeks with an NGT in situ, before considering a PEG to ensure a better outcome. Others [14] consider the prognosis and argue that a patient at the end stages of a disease should not be considered for PEG but should rather receive nutrition via NGT. No difference between NGT and PEG cohorts was found in the rate of complications [46], the rate of mortality post placement [45-46] or the occurrence of pneumonia post placement [46].

Higher complication rates for gastrostomies relative to PEG placements have been reported [57-58]. Complications include internal leakage, peritonitis, fistula, dislodgement, external leakage and skin infection. Higher mortality rates in surgical gastrostomy cases (29%, n=35) compared with PEG cases (17%, n=12) were not significantly different [58].

The reasons for high mortality rates include poor patient selection. Patients with risk factors for mortality have been recommended for a PEG resulting in poor outcomes that are being linked to the PEG procedure, when in fact these patients were at risk of death regardless of PEG placement [59-60]. There is strong evidence linking certain underlying medical conditions to higher mortality post PEG [5, 15, 36, 55-56, 59, 61-63]. The highest mortality rates occurred in patients who had CVA and malignancies [22, 62].

The timing of PEG placement [24, 64] is noted also to affect the outcome. It has been suggested that there be a 30 day delay in the placement of long term enteral nutrition to ensure a better chance of survival, leaving patients on short term enteral nutrition for a longer period [24, 64]. The notion of poor timing in the placement of PEG is linked to poor patient selection. If a patient has an underlying medical condition that places them at risk for mortality, it can be argued that they would have died regardless, and early PEG insertion, at a time when they are at risk of death due to an underlying medical condition, means that they die with a PEG in situ which makes their death a statistic of mortality post PEG placement. To counteract early PEG placement, it is suggested that if a patient has survived and still requires a PEG after their condition has stabilised, only then should it be considered. Abuksis et al. (2000) noted a lower mortality rate in patients who were deferred for the placement of a PEG until they were discharged from hospital and if it was still required at 30 days post discharge.

As an example, mortality in patients with CVAs usually occurs in the acute stage when a patient is still in the hospital [65]. Dysphagia is common following a CVA [65] and many CVA patients will regain their ability to swallow within two weeks post infarct [66]. A patient who receives a PEG at this stage is at high risk of dying due to the underlying medical condition of a CVA [65]. The high mortality will be reflected as a consequence of PEG placement in cases with a CVA. The timing for the placement of a PEG in a patient with a CVA is critical, and should only be considered if a patient has not regained their ability to swallow within four weeks [13, 67]. During the acute stages post CVA, an NGT is recommended for the provision of hydration and nutrition [13].

There are also a series of risk factors such as increased age, decreased body mass index, a higher number of co-morbidities, and decreased blood albumin levels have been identified as placing a patient at greater risk of mortality post PEG. Along with the primary medical condition and timing of placement, these factors also need to be considered when recommending a patient for a PEG to reduce the likelihood of poor outcomes. One such risk factor is increased age. Patients over the age of 60 were found to have the highest mortality rate at 30-days post insertion [20, 22-25, 55-56, 68-70]. Age together with diminished mental capacity, as with patients who have dementia, tripled mortality in the period after placement [22]. Such outcomes caution against PEG placement in older patients with dementia.

The positive outcomes of long term enteral nutrition should also guide decisions for such a recommendation. One such outcome post PEG placement is the ability to return to oral intake which can occur in patient populations with a range of medical conditions and depends on factors such as the presence of dysphagia, age, and the underlying medical condition that necessitated PEG placement [12, 17, 69]. Factors that determined a return to oral intake, were the ability to take some amount of nutrition orally at 3 and 6 months post PEG placement [12], regression of the tumour that had originally caused dysphagia post chemo/radiotherapy [12, 17] regaining of the swallow post CVA [12, 69], a younger age, the absence of dysphagia and intervention by a speech therapist to regain the swallow pre PEG placement [71].

The provision of nutrition into the stomach via NGT or gastrostomy/PEG is common [5, 21]. Gastrointestinal intolerance of tube feedings, identified by the presence of large gastric residual volumes, nausea and vomiting, ileus, abdominal distension, and diarrhoea [72], is a major factor limiting adequate enteral intake in patients. In cases such as these the stomach may be bypassed and nutrition delivered to a lower part of the gastro intestinal tract [4, 39, 73]. NJT/PEJ enteral nutrition has been noted to result in better energy intake due to improved absorption in the small bowel and a decreased risk of reflux related aspiration due to feeds being delivered into an area further away from the pharynx [74]. However, Davies et al. (2012) report no difference in energy intake and risk of aspiration between patients receiving enteral nutrition via NGT and NJT.

5. Decision making between the different routes of enteral nutrition

PEGs, GTs and NGTs have advantages and possible complications. The outcomes relate to mortality and improved nutrition. Adequate nutrition is linked to better medical outcomes and survival [35, 73]. PEG is noted to be superior to NGT with regard to improvement in general medical outcomes [46] with NGT candidates being statistically more prone to intervention failure, such as tube blockage or leakage, feed interruption and recurrent displacement, than patients who were fitted with PEG, regardless of the patient’s underlying medical condition [46]. With better provision of feeds when a PEG is used, better medical outcomes may be expected as a patient is more likely to receive adequate hydration and nutrition.

When patients who had a CVA were considered as a separate group from other medical conditions, neither NGT nor PEG were superior in the delivery of nutrition. The presence of dysphagia was the key indicator for mortality rather than the type of enteral nutrition used [36].

There exists debate around which method of enteral intake is best suited for patients with head and neck cancer specifically. A large majority of patients with cancer are malnourished throughout the disease process and require enteral nutrition [75]. Determining the optimal mode of enteral nutrition in this patient population bears consideration of the benefits and drawbacks. Sobani et al. (2011) reported PEG as being superior to NGT in that it resulted in greater weight gain and lower mortality, but others [76] note a lower clinical risk of complications, and a greater chance of returning to full oral intake after a six month period, with patients left on NGT rather than fitted with a PEG. It was argued that a patient with an NGT would be more eager to feed orally in order to progress towards removal of the tube because of the visibility of an NGT, which can be unsightly to some. Beginning partial oral intake made muscle atrophy less likely and sped up the return to full oral intake, compared to those receiving nutrition exclusively via a PEG [76]. In patients with dysphagia and a range of medical conditions including neurological fallout and head and neck cancer, Gomes et al. (2012) noted no difference in mortality rates post PEG or NGT placement.

Mortality rates after PEG placement has been reported to be low as a direct result of the PEG procedure [11, 77]. However, Malmgren et al. (2011) suggest that the mortality rate in the first few weeks post PEG placement is ‘high’ and ranges between 10% and 36% depending on sample size and medical conditions [5, 22, 55-56, 69, 78-79). The greatest majority of patients died within a 30 day period post PEG placement and in patients with dementia, the mortality rate was as high as 54% [79]. The 30 day mortality rates were from both developed and developing countries where a variety of medical conditions were included in the sample.

Strong evidence links poor nutrition upon hospitalization with poor medical outcomes, such as greater incidence of morbidity and mortality [45, 73, 80]. Malnourishment is measured using the body mass index (BMI), with a BMI of <18.5 indicating malnutrition (WHO, 1995). Malnourishment can be as a result of the disease process or due to socioeconomic factors [81] and can be further exacerbated by hospitalization [13, 15, 35, 44, 48, 56, 73], because of interruptions in the provision of enteral nutrition, inadequate nutrition prescribed and the inability of a patient, who may be on oral intake, to physically eat independently [81]. Malnourishment at the time of PEG placement is a crucial factor noted to place a patient at risk for mortality [19, 45, 55-56, 70, 77].

30 day mortality rate (%) Sample size
(N)
Medical condition Country Researchers
15.8%359Head and neck cancer (n=97)
CVA (n=73)
Malignancy (n=61)
Head injury (n=59)
Cerebral palsy (n=38)
Congenital anomaly (n=19)
Motor neuron disease (n=7)
Dementia (n=5)
Bosnia HerzegovinaVanis, Saray, Gornjakovic & Mesihovic, 2012
22%201CVA (n=97)
Malignant oesophageal obstruction (n=33)
Dementia (n=16)
Other neurologic disorders (n=13) Parkinsons (n=12)
Other (n=23)
Other malignancies (n=5)
SwedenMalmgren et al., 2011
10%77Neurologic disorders (n=71)
Head and neck cancer (n=6)
TurkeyErmis et al., 2012
20%128CVA (n=34)
Non neurologic cerebral hypoxia (n=30)
Cranial tumour (n=23)
Head and neck cancer (n=19)
Motor neuron disease (n=13)
Other (n=9)
Turkey Gundogan et al., 2014
19%83CVA (n=83)NorwayHa & Hauge, 2003
22%112CVA (n=33)
Head and neck cancer (n=27)
Chronic neurological disorders (n=22)
Other (n=30)
Britain Longcroft-Wheaton et al., 2009
18.5%187Malignancy (n=187)USAKeung et al., 2012
36%61 CVA (n=50)
Dementia (n=21)
Malignancy (n=9)
Head and neck trauma (n=3)
IsraelAbuksis et al., 2004
28%361CVA (n=120)
Dementia (n=103)
Oropharyngeal malignancy (n=65)
Other (n=73)
USASanders et al., 2000

Table 1.

International mortality rates 30 days post PEG placement

Upon admission to hospital an NGT may be placed to improve nutrition before placement of a PEG [77]. But NGT feeds can result in minimal improvement in nutritional status because of interrupted feeds when the patient has a procedure, late placement and commencement of feeds or accidental removal of tubes [47-48, 72]. A nutritionally compromised patient would benefit from placement of a PEG with the aim of improving nutrition, based on evidence that PEG placement facilitates better improvement in nutrition [5, 75]. However PEG placement comes with a high risk of mortality due to the patient’s initial poor nutritional status.

Based on the high mortality rate of malnourished patients, it is important to consider the nutritional status of individuals prior to PEG placement [19, 45, 55-56, 70, 77]. A review of the literature suggests that albumin levels may be used as a marker of a patient’s nutritional status [82]. Albumin is a protein made by the liver, and is a measure of protein in the body. Albumin balances the amount of blood flowing through the body’s arteries and veins and helps to transport calcium, progesterone, bilirubin and medications through the blood. A serum albumin test will measure the amount of protein in the blood and can be used as an indicator of the presence of liver or kidney disease [83] which can affect patient survival. Normal levels of albumin are considered to be in the range of 3.4-5.4 g/dL or 35-50 g/L, depending on how specific laboratories measure it. Blomberg et al., (2011) noted the link between low albumin levels pre-insertion of PEG and a high mortality rate post insertion. This link confirms that hypo- albuminaemia is a risk factor that should be considered in all patients being medically worked up for PEG placement [45, 56, 59, 77, 84]. Co morbidities like diabetes and cardiac disease were also noted to be significant risk factors for high mortality in patients post PEG placement [19, 56, 59, 70, 82].

6. The role of the speech language therapist (SLT)

Evidence exists to support the involvement of an SLT in the assessment and treatment of patients with dysphagia. Langmore et al. (2011) [108] suggested that it is important for an SLT to assess a patient with head and neck cancer and to determine the most optimal approach for each patient to be able to recover swallowing or to compensate for losses due to surgical or chemo-radiation intervention. The role of the SLT in the management of patients with dysphagia who may require enteral nutrition, is not to recommend the route of enteral nutrition, but rather to make a recommendation of whether or not the patient can eat orally and is safe to do so. All discussions and decisions relating to enteral nutrition, whether short or long term, should take place within an inter-professional team including the patient and caregivers.

Considering the multitude of risk factors that exist for poor outcomes post PEG insertion, it follows that a patient should be individually assessed for the presence of any risk factors before being recommended for the procedure [85-87]. A comprehensive assessment by the team needs to consider factors such as: 1) the potential benefits to the individual should they receive a PEG, 2) biochemical parameters, like blood albumin level, 3) multiple comorbidities, 4) prognosis, 5) and the presence of risk factors that may place a patient at risk of mortality post procedure, such as being over the age of 60 years and a low BMI [10, 19, 23, 25, 45, 56, 69, 87-89, 90].

Strong emphasis is placed upon a team approach when assessing patients who may be recommended for long term enteral nutrition [85-87]. A rigorous assessment, by a team, for each patient being considered for a PEG ought to be in place. The team needs to ensure that all risk factors which could affect outcome are considered and that an informed decision respects patient autonomy [60, 85-87]. A patient who is considered a high risk for mortality should not be considered a candidate for the procedure as it would be a futile intervention. Better patient selection would improve the outcome of patients who are recommended for and fitted with a PEG [91].

7. Ethical considerations

A patient may refuse a NGT or a PEG procedure and wish to begin/ continue oral intake, even if it means a shorter survival period. Patient’s decisions need to be honoured and respected by health care professionals [92].

Where patients opt for enteral nutrition, despite the benefits that enteral nutrition can provide a patient, such as improved nutrition and a longer survival time, quality of life is affected [93]. Health care professionals should counsel patients on the effects that a PEG tube will have on their quality of life [94], by shifting the focus of management post PEG insertion to include social aspects and not only clinical needs [95].

The placement of a PEG for the provision of enteral nutrition is considered a life-saving procedure in some cases [93, 96] and many patients who have a PEG attest to this fact and the benefit that PEG feeding provides them [96-97]. One study noted particularly positive patient reports on their experiences living with a PEG tube, with 84% (N=51) noting a positive or neutral effect of the tube on their lives, 90% (N=51) expressing a view that the tube was worthwhile and 96% (N=51) noting that they would recommend it to another patient [97].

Negative experiences that a PEG has on patients’ quality of life have been extensively reported. Common difficulties associated with having a PEG tube, which affect quality of life, include a high level of complication, like tube blockage, leakage and discomfort [94] interference with family life, social activities and hobbies [93-94, 98-99], interference with intimacy [94], negative reactions from others [95], a burden placed on family or caregivers [95] and a feeling of missing out on meal times and food [95]. Similar negative effects on quality of life are reported in patients who receive NGT feeds [98]. A study in Taiwan noted that the majority of patients are discharged home on NGT feeds because of a refusal to have a PEG placed [100]. Reasons included concern over leakage and infection following a PEG, a worry that the patient is too old and frail to undergo an operation and a cultural belief that the patient will not die “whole” if they have a PEG in situ [100].

In light of the high mortality rate post PEG placement, the concept of futility bears discussion. Futility refers to a medical intervention that would have no effect, or if there was an effect, it would not be one that the patient benefitted from [89]. Many patients receive long term enteral nutrition where no effect or benefit is proven in terms of nutritional improvement or survival [56]. All aspects linked to possible mortality must be considered, and risks and benefits weighed before a recommendation for enteral nutrition is made. If a patient is considered to be a high risk for mortality, certain procedures that will cause further suffering and no benefit may be deemed futile [7], and should be avoided [21]. The decision to place a PEG should be based on the perceived benefit it will bring to the patient [89] and if no benefit is presumed, then the procedure should not be done. A patient who is identified as a high risk for mortality post PEG placement should not receive a PEG but rather they and their families should be counselled on the risks that exist and the reasons for deferred placement. A team can make a recommendation for enteral nutrition based on their knowledge but a cognitively intact patient must make the final decision after being fully informed about the benefits and risks involved in the proposed management plans [89].

The issue of futility in PEG placement is most particularly noted in the case of patients with advanced dementia being fitted with a tube for the provision of long term enteral nutrition [101-102]. In this population, the placement of a PEG has no benefit to the patient and can actually lead to decreased survival due to complications, such as aspiration, that result from the placement [89, 102]. The use of long term enteral nutrition in patients with malignancy, with the aim of nutritional gain, needs to be questioned as there is no real nutritional gain in these patients post placement [16, 62, 78].

Azzopardi and Ellul (2013) suggest that, in certain patient populations, the insertion of a PEG will only prolong a life which is of poor quality and it needs to be determined through discussion whether this decision is ethical. A consideration in South Africa particularly, is whether it would be appropriate to perform futile procedures in a resource constrained public hospital sector [103]. If PEGs are placed in cases where patients have poor prognosis and are considered high risk for mortality post PEG placement, an argument could be made that the scarce resources would be better directed to those patients with potentially better outcomes.

The use of protocols in patient care ensures adherence with best practice. They are important documents to which health care professionals should refer to guide practice that will result in the provision of the best possible care [104]. Protocols for the assessment and management of patients with dysphagia who require enteral nutrition exist [2, 38, 66, 105] but do not include considerations like assessment of risk factors to justify the PEG procedure. Further, adherence to protocols cannot be assumed. The presence of risk factors in patients do not always deter health professionals in making a recommendation for PEG placement, as is evident by the persistence of high mortality rates, despite the known effects of risk factors and their effect on mortality [56].

8. End of life and enteral nutrition

The decision to refer a patient for a PEG placement or not, includes holistic consideration of many factors to make a recommendation that is in the best interests of the patient.

The provision of hydration and nutrition at the end of life care is an area of debate and can become a highly emotional topic. Delegge et al. (2005) suggest that the decision to place a feeding tube consider the basic principles of professional ethics. Informed consent from an adult who is cognitively intact is imperative, and the benefits of the placement of enteral nutrition must outweigh the risk of the procedure, which should cause the patient no harm [89].

The concept of palliative care needs to be introduced as a real alternative for patients who are not considered candidates for PEG placement due to the presence of risk factors that place them at high risk for mortality. The World Health Organisation (2002) considers palliative care as “...an all-encompassing approach to care that begins months or years before death”. PEG placement does not always benefit the patient, and although the actual PEG procedure does not harm the patient, the risk of mortality post placement is high, which in turn is harmful to the patient. The choice of refusing a PEG and remaining on oral intake as a form of palliative care should be made available to all patients and their caregivers, with provision of education and support for the decision they may make. The inclusion of a palliative care option for patients who do not wish to have a PEG placed would provide them with an alternative option, and it would also ensure that futile procedures are avoided which would uphold medical ethics.

The decisions around the recommendation of enteral nutrition, particularly in very ill patients who have a poor prognosis, are not easy for health care professionals to make. Clear guidelines that are based on evidence are crucial in order to help health care professionals navigate these difficult decisions that are often clouded with human emotion.

A role not often considered by SLTs is that of palliative care. The provision of artificial nutrition and hydration (ANH) to patients who are in the end stages of disease is debated, and can evoke emotional responses [106]. It is common for patients in the end stages of disease to have little or no oral intake [106]. Many practitioners may feel that depriving a patient of hydration and nutrition is unethical and can make health professionals uncomfortable [89,107]. A study of nurses’ perceptions on ANH in palliative care yielded more clinical reasons for withholding of ANH than for providing it [106]. Reasons supporting provision of ANH were emotive, not based on clinical fact and were not in the best interests of the patient [106].

In practice, there comes a time, when a decision needs to be made about the hydration and nutrition needs of a patient in the end stages of disease. The SLT is often the professional who, based on the assessment of the patient’s swallowing, is in a position to determine the feasibility of nutritional intake. It is important that the SLT and the inter-professional team are educated in the field of palliative care and ANH [106-107] to contribute to making an informed decision regarding a patient’s options at end of life and reduce the number of inappropriate referrals for futile procedures with poor outcomes.

9. Conclusion

Based on a review of current literature some important points have been raised around the recommendation process for enteral nutrition in adult patients with dysphagia. The key focus in any decision making process for medical procedures should be on patient autonomy. If a patient consents to placement of a PEG for the provision of long term enteral nutrition, with a full understanding of the impact it will have on them, not only medically but socially and emotionally too, then a standard assessment procedure needs to follow. Assessment should be carried out by a team of health care professionals, including the SLT, and should include a consideration of the patients underlying medical condition, indication for PEG, prognosis of survival post procedure, age, nutritional status, the presence of co-morbidities and biochemical parameters. Based on the assessment findings, the team, in conjunction with the patient and their family, need to make a recommendation. If a patient is considered to be a high risk for mortality following PEG placement then alternate methods of intake need to be discussed with and recommended to the patient and their family, with education and counselling provided on the benefits and risks of oral intake as a form of palliation. A thorough assessment procedure will help to ensure that futile procedures are avoided and only patients who consent to and who will benefit from PEG placement are recommended for the procedure.

References

1 - Lochs, H., Dejong, C., Hammarqvist, F., Hebuterne, X., Leon-Sanz, M., Schtz, T., van Gemert, W., van Gossum, A., Valentini, L., Lubke, H., Bischoff, S., Engelmann, N., & Thul, P. (2006). ESPEN Guidelines on Enteral Nutrition: Gastrosenterology. Clinical Nutrition, 25, 260-274. DOI:10.1016/j.clnu.2006.01.007.
2 - Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B., Metheny, N.A., Mueller, C., Robbins, S., & Wessel, J. (2009). A.S.P.E.N. Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition, 33, 122. DOI: 10.1177/0148607108330314.
3 - Blomberg, J., Lagergren, J., Martin, L., Mattsson, F., & Lagergren, P. (2012). Complications after percutaneous endoscopic gastrostomy in a prospective study. Scandinavian Journal of Gastroenterology, 47(6), 737-742. DOI:10.3109/00365521.2012.654404.
4 - DiBaise, J. K., & Scolapio, J. S. (2007). Home parenteral and enteral nutrition. Gastroenterology Clinics of North America, 36(1), 123. DOI:10.1016/j.gtc.2007.01.008.
5 - Erdil, A., Saka, M., Ates, Y., Tuzun, A., Bagci, S., Uygun, A., Yesilova, Z., Gulsen, M., Karaeren, N., & Dagalp, K. (2005). Enteral nutrition via percutaneous endoscopic gastrostomy and nutritional status of patients: Five-year prospective study. Journal of Gastroenterology & Hepatology, 20(7), 1002-1007. DOI:10.1111/j.1440-1746.2005.03892.
6 - Gundogan, K., Yurci, A., Coskun, R., Baskol, M., Gursoy, S., Hebbar, G., Ziegler, T. R. (2014). Outcomes of percutaneous endoscopic gastrostomy in hospitalized patients at a tertiary care center in turkey. European Journal of Clinical Nutrition, 68(4), 437-440. DOI:10.1038/ejcn.2014.11.
7 - Holmes, S. (2011). Importance of nutrition in palliative care of patients with chronic disease. Primary Health Care, 21(6), 31-39. Retrieved from http://web.b.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=bbcd98c7-51e6-44f0-bbfa-91fbc7040303%40sessionmgr113&vid=1&hid=110.
8 - Sharp, H. M., & Shega, J. W. (2009). Feeding tube placement in patients with advanced dementia: The beliefs and practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology, 18(3), 222-230. DOI:10.1044/1058-0360(2008/08-0013.
9 - Vivanti, A. P., Campbell, K. L., Suter, M. S., Hannan-Jones, M., & Hulcombe, J. A. (2009). Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. Journal of Human Nutrition and Dietetics: The Official Journal of the British Dietetic Association, 22(2), 148-155. DOI:10.1111/j.1365-277X.2009.00944.
10 - Kobayashi, K., Cooper, G. S., Chak, A., Sivak Jr., M. V., & Wong, R. C. K. (2002). A prospective evaluation of outcome in patients referred for PEG placement. Gastrointestinal Endoscopy, 55(4), 500-506. DOI:10.1067/mge.2002.122577.
11 - Nicholson, F. B., Korman, M. G., & Richardson, M. A. (2000). Percutaneous endoscopic gastrostomy: A review of indications, complications and outcome. Journal of Gastroenterology & Hepatology, 15(1), 21-25. DOI:10.1046/j.1440-1746.2000.02004.
12 - Paramsothy, S., Papadopoulos, G., Mollison, L. C., & Leong, R. W. L. (2009). Resumption of oral intake following percutaneous endoscopic gastrostomy. Journal of Gastroenterology & Hepatology, 24(6), 1098-1101. DOI:10.1111/j.1440-1746.2009.05802.
13 - Prosser-Loose, E., & Paterson, P. G. (2006). The FOOD trial collaboration: Nutritional supplementation strategies and acute stroke outcome. Nutrition Reviews, 64(6), 289-294. DOI:10.1301/nr.2006.jun.289-294.
14 - Rio, A., Ellis, C., Shaw, C., Willey, E., Ampong, M., Wijesekera, L., Rittman, T., Nigel Leigh, P.,
15 - Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital patients. Gut, 52 (Suppl VII):vii1-vii12. DOI: 10.1136/gut.52.suppl_7.vii1.
16 - Baldwin, C., Spiro, A., McGough, C., Norman, A. R., Gillbanks, A., Thomas, K., Cunningham, D., O'Brien, M., & Andreyev, H. J. N. (2011). Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: A randomised controlled trial. Journal of Human Nutrition & Dietetics, 24(5), 431-440. DOI:10.1111/j.1365-277X.2011.01189.
17 - Nguyen, N. P., North, D., Smith, H. J., Dutta, S., Alfieri, A., Karlsson, U., Lee, H., Martinez, T., Lemanski, C., Nguyen, L. M., Ludin, A., & Sallah, S. (2006). Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation. Surgical Oncology, 15(4), 199-203. DOI:http://dx.doi.org.ezproxy.uct.ac.za/10.1016/j.suronc.2006.12.002.
18 - Wermker, K., Jung, S., Huppmeier, L., Joos, U., & Kleinheinz, J. (2012). Prediction model forearly percutaneous endoscopic gastrostomy (PEG) in head and neck cancer treatment. Oral Oncology, 48, 355-360. DOI:10.1016/j.oraloncology.2011.11.005.
19 - Longcroft-Wheaton, G., Marden, P., Colleypriest, B., Gavin, D., Taylor, G., & Farrant, M. (2009). Understanding Why Patients Die After Gastrostomy Tube Insertion: A Retrospective Analysis of Mortality. Journal of Parenteral and Enteral Nutrition, 33 (4), 375-379. DOI: 10.1177/0148607108327156.
20 - Kirchgatterer, A., Bunte, C., Aschl, G., Fritz, E., Hubner, D., Kranewitter, W., Fleischer, M., Hinterreiter, M., Stadler, B., & Knoflach, P. (2007). Long-term outcome following placement of percutaneous endoscopic gastrostomy in younger and older patients. Scandinavian Journal of Gastroenterology, 42(2), 271-276. DOI:10.1080/00365520600880864.
21 - Lee, C., Im, J., Kim, J., Kim, S., Ryu, D., Cha, J.M., E.Y., Kim, E.R., & Chang, D. (2013). Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: A multicenter, retrospective study. Surgical Endoscopy, 27(10), 3806-3815. DOI:10.1007/s00464-013-2979-3.
22 - Malmgren, A., Hede, G. W., Karlström, B., Cederholm, T., Lundquist, P., Wirén, M., & Faxén-Irving, G. (2011). Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food & Nutrition Research, 55, 1-6. DOI:10.3402/fnr.v55i0.6037.
23 - Richter-Schrag, H-J., Richter, S., Ruthmann, O., Olschewski, M., Hopt, UT., & Fischer, A. (2011). Risk factors and complications following percutaneous endoscopic gastrostomy: A case series of 1041 patients. Canadian Journal of Gastroenterology, 25(4), 201-206. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy.uct.ac.za/pmc/articles/PMC3088695/pdf/cjg25201.pdf.
24 - Smith, B., Perring, P., Engoren, M., & Sferra, J. J. (2008). Hospital and long-term outcome after percutaneous endoscopic gastrostomy. Surgical Endoscopy, 22(1), 74-80. DOI:10.1007/s00464-007-9372-z.
25 - Smoliner, C., Volkert, D., Wittrich, A., Sieber, C. C., & Wirth, R. (2012). Basic geriatric assessment does not predict in-hospital mortality after PEG placement. BMC Geriatrics, 12, 52-52. DOI:10.1186/1471-2318-12-52.
26 - Thomson, M. A., Carver, A. D., & Sloan, R. L. (2002). Percutaneous endoscopic gastrostomy feeding in a district rehabilitation service. Clinical Rehabilitation, 16(2), 215-220. DOI:10.1191/0269215502cr476oa.
27 - Crary, M. A., Humphrey, J. L., Carnaby-Mann, G., Sambandam, R., Miller, L., & Silliman, S. (2012). Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia 28(1), 69-7. DOI:10.1007/s00455-012-9414-0.
28 - Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly: Management and nutritional considerations. Clinical Interventions in Aging, 7, 287-298. DOI:10.2147/CIA.S23404.
29 - Darbar, A. (2001). Nutritional Requirements in Severe Head Injury. Nutrition, 17, 71-72. PII S0899-9007(00)00476-7.
30 - Denes, Z. (2004). The influence of severe malnutrition on rehabilitation in patients with severe head injury. Disability and Rehabilitation, 26(19), 1163-1165. DOI: 10.1080/09638280412331270380.
31 - Hartl, R., Gerber, L.M., Quanhong, N., & Ghajar, J. (2008). Journal of Neurosurgery, 109, 50-59. DOI: 10.3171/JNS/2008/109/7/0050.
32 - Vizzini, A., & Aranda-Michel, J. (2011). Nutritional support in head injury. Nutrition, 27(2), 129-132. DOI:10.1016/j.nut.2010.05.004.
33 - Zhang, L., Sanders, L., & Fraser, R. J. L. (2012). Nutritional support teams increase percutaneous endoscopic gastrostomy uptake in motor neuron disease. World Journal of Gastroenterology: WJG, 18(44), 6461. DOI:10.3748/wjg.v18.i44.6461.
34 - de Aguilar-Nascimento, J. E., Bicudo-Salomao, A., & Portari-Filho, P. (2012). Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions, Nutrition, 28(9), 840-843. DOI:10.1016/j.nut.2012.01.013.
35 - Vassilyadi, F., Panteliadou, AK., & Panteliadis, C. (2013). Hallmarks in the History of Enteral and Parenteral Nutrition : From Antiquity to the 20th Century. Nutrition in Clinical Practice, 28: 209. DOI: 10.1177/0884533612468602.
36 - Laskaratos, F., Walker, M., Walker, M., Gowribalan, J., Gkotsi, D., Wojciechowska, V.,... Jenkins, A. (2013). Predictive factors for early mortality after percutaneous endoscopic and radiologically-inserted gastrostomy. Digestive Diseases and Sciences. DOI 10.1007/s10620-013-2829-0.
37 - Swaminath, A., Longstreth, G.F., Runnman, E.M., Yang, S.J. (2010). Effect of Physician Education and Patient Counseling on Inpatient Nonsurgical Percutaneous Feeding Tube Placement Rate, Indications, and Outcome. Southern Medical Journal, 103 (2), 126-130. DOI: 10.1097/SMJ.0b013e3181c9800f.
38 - Wilhelm, S.M., Ortega, K.A., Stellato, T.A. (2010). Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement. The American Journal of Surgery, 199, 396-400.
39 - McClave, S. A., & Chang, W. (2003). Complications of enteral access. Gastrointestinal Endoscopy, 58(5), 739-751. DOI:http://dx.doi.org.ezproxy.uct.ac.za/10.1016/S0016-5107(03)02147-3.
40 - Maitines, G., Ugenti, I., Memeo, R., Clemente, N., & Lambrenghi, O.C. (2009). Endoscopic gastrostomy for enteral nutrition in neurogenic dysphagia: Application of a nasogastric tube or percutaneous endoscopic gastrostomy. Chirurgia Italiana Journal 61(1), 33-38. Retrieved from http://europepmc.org/abstract/med/19391337.
41 - Davies, A. R., Morrison, S. S., Bailey, M. J., Bellomo, R., Cooper, D. J., Doig, G. S., Finfer, S.R., & Heyland, D. K. (2012). A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Critical Care Medicine, 40(8), 2342-2348. DOI: 10.1097/CCM.0b013e318255d87e.
42 - Doig, G. S., Heighes, P. T., Simpson, F., & Sweetman, E. A. (2011). Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomized controlled trials. Injury, 42, 50-56. DOI:10.1016/j.injury.2010.06.008.
43 - Lu, G., Huang, J., Yu, J., Zhu, Y., Cai, L., Gu, Z., & Su, Q. (2011). Influence of early post-burn enteral nutrition on clinical outcomes of patients with extensive burns. Journal of Clinical Biochemistry and Nutrition, 48(3), 222-225. DOI:10.3164/jcbn.10-91.
44 - Silva, M.A., dos Santos, S.G.F., Tomasi, C. D., da Luz, G., Paula, M.M., Dal Pizzol, F., & Ritter, C. (2013). Enteral nutrition discontinuation and outcomes in general critically ill patients. Clinics (São Paulo, Brazil), 68(2), 173-178. DOI: 10.6061/clinics/2013(02)OA09.
45 - Azzopardi, N., & Ellul, P. (2013). Pneumonia and mortality after percutaneous endoscopic gastrostomy insertion. The Turkish Journal of Gastroenterology: The Official Journal of Turkish Society of Gastroenterology, 24(2), 109-116. DOI: 10.4318/tjg.2013.0512.
46 - Gomes, C.A.R., Lustosa, S. A. S., Matos, D., Andriolo, R., Waisberg, D. R., & Waisberg, J. (2012). Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database of Systematic Reviews, 3, 1-50. DOI:10.1002/14651858.CD008096.pub3.
47 - Beavan, J., Conroy, S. P., Harwood, R., Gladman, J. R. F., Leonardi-Bees, J., Sach, T., Bowling, T., Sunman, W., & Gaynor, C. (2010). Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age and Ageing, 39, 624-630. DOI: 10.1093/ageing/afq088.
48 - Kim, H., Stotts, N. A., Froelicher, E. S., Engler, M. M., Porter, C., & Kwak, H. (2012). Adequacy of early enteral nutrition in adult patients in the intensive care unit. Journal of Clinical Nursing, 21, 2860-2869. DOI:10.1111/j.1365-2702.2012.04218.
49 - Roy, P., Person, B., Souday, V., Kerkeni, N., Dib, N., & Asfar, P. (2005). Percutaneous radiologic gastrostomy versus nasogastric tube in critically ill patients. Clinical Nutrition, 24(2), 321-325. DOI:10.1016/j.clnu.2004.11.006.
50 - Wu, P.Y., Kang, T.J., Hui, C.K., Hung, M.H., Sun, W.Z., & Chan, W.H. (2006). Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis. Journal of Formosan Medical Association, 105, pp. 80-85
51 - Hegde, H., V., & Rao, P. R. (2010). A near miss; malpositioned nasogastric tube in the left bronchus of a spontaneously breathing critically-ill patient. Current Anaesthesia & Critical Care, 21, 94-96. DOI:10.1016/j.cacc.2009.12.002.
52 - Dziewas, R., Ritter, M., Schilling, M., Konrad, C., Oelenberg, S., G., Nabavi, D., Stogbauer, F., Ringelstein, E.B., & Lüdemann, P. (2004). Pneumonia in acute stroke patients fed by nasogastric tube. Journal of Neurology, Neurosurgery & Psychiatry, 75(6), 852-856. DOI:10.1136/jnnp.2003.019075.
53 - Mizock, B.A. (2007). Risk of Aspiration in Patients on Enteral Nutrition: Frequency, Relevance, Relation to Pneumonia, Risk Factors, and Strategies for Risk Reduction. Current Gastroenterology Reports, 9, 338-344. Retrieved from http://link.springer.com.ezproxy.uct.ac.za/journal/11894/9/4/page/1.
54 - Jung, S.H., Dong, S. H., Lee, J.Y., Kim, N.H., Jang, J.Y., Kim, H.J., Kim, B.H., Chang, Y.W., & Chang, R. (2011). Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Re?ux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24- Hour pH Monitoring. Gut and Liver, 5(3), 288-292. DOI.org/10.5009/gnl.2011.5.3.28.
55 - Abuksis, G., Mor, M., Plaut, S., Fraser, G., & Niv, Y. (2004). Outcome of percutaneous endoscopic gastrostomy (PEG): Comparison of two policies in a 4-year experience. Clinical Nutrition (Edinburgh, Scotland), 23(3), 341-346. DOI:10.1016/j.clnu.2003.08.001.
56 - Johnston, S. D., Tham, T. C. K., & Mason, M. (2008). Death after PEG: Results of the national confidential enquiry into patient outcome and death. Gastrointestinal Endoscopy, 68(2), 223-227. DOI:10.1016/j.gie.2007.10.019.
57 - Dwyer, K.M., Watts, D.D., Thurber, J.S., Benoit, R.S., & Fakhry, S.M. (2002). Percutaneous endoscopic gastrostomy: The preferred method of elective feeding tube placement in trauma patients. Trauma, 52, 26-32. Retrieved from http://journals.lww.com/jtrauma/Abstract/2002/01000/Percutaneous_Endoscopic_Gastrostomy__The_Preferred.7.aspx.
58 - Moller, P., Lindberg., C-G., & Zilling, T. (1999). Gastrostomy by various techniques: Evaluation of indications, outcome, and complications. Scandanavian Journal of Gastroenterology,34, 1050-1054.
59 - Kurien, M., Leeds, J. S., Robson, H. E., James, G., Hoeroldt, B., Dear, K., Kapur, K., Grant, J., McAlindon, M.E., & Sanders, D. S. (2011). Survival following gastrostomy insertion: Are there differences in mortality according to referral indication? Gut, 60,A18-A19. DOI: 10.1136/gut.2011.239301.37.
60 - Richards, D., Tanikella, R., Arora, G., Guha, S., & Dekovich, A. (2013). Percutaneous endoscopic gastrostomy in cancer patients: Predictors of 30-day complications, 30-day mortality, and overall mortality. Digestive Diseases & Sciences, 58(3), 768-776. DOI:10.1007/s10620-012-2397-8.
61 - Grant, D. G., Bradley, P. T., Pothier, D. D., Bailey, D., Caldera, S., Baldwin, D. L., & Birchall, M. A. (2009). Complications following gastrostomy tube insertion in patients with head and neck cancer: A prospective multi-institution study, systematic review and meta-analysis. Clinical Otolaryngology, 34(2), 103-112. DOI:10.1111/j.1749-4486.2009.01889.
62 - Poulose, B., Kaiser, J., Beck, W., Jackson, P., Nealon, W., Sharp, K., & Holzman, M. (2013). Disease-based mortality after percutaneous endoscopic gastrostomy: Utility of the enterprise data warehouse. Surgical Endoscopy, 27(11), 4119-4123. DOI:10.1007/s00464-013-3077-2.
63 - Schettler, A., Momma, M., Markowski, A., Schaper, R., Klamt, S., Vaezpour, R., & Schneider, A. (2013). Pp215-mon complication rate and mortality after percutaneous endoscopic gastrostomy are low and depend on the indication. Clinical Nutrition, 32, S202-S202. DOI:10.1016/S0261-5614(13)60525-7.
64 - Abuksis, G., Mor, M., Segal, N., Shemesh, I., Plout, S., Sulkes, J., Fraser, G.M., & Niv, Y. (2000). Percutaneous endoscopic gastrostomy: High mortality rates in hospitalized patients. The American Journal of Gastroenterology, 95(1), 128-132. DOI:10.1111/j.1572-0241.2000.01672.x.
65 - Cowey, E. (2012). End of life care for patients following acute stroke. Nursing Standard, 26(27), 42-46. Retrieved from http://web.b.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=be9f53c3-a7f3-4c75-a392-ffef3e0bcec7%40sessionmgr198&vid=1&hid=110.
66 - Westaby, D., Young, A., O'Toole, P., Smith, G., & Sanders, D.S. (2010). The provision of a percutaenously placed enteral tube feeding service. Gut, 59, 1592-1605. DOI:10.1136/gut.2009.204982.
67 - Kumar, S., Langmore, S., Goddeau, R., J., Alhazzani, A., Selim, M., Caplan, L. R., Zhu, L.,
68 - Grant, M. D., Rudberg, M. A., & Brody, J. A. (1998). Gastrotomy placement and mortality among hospitalized medicare beneficiaries. JAMA: The Journal of the American Medical Association, 279(24), 1973-1976. Retrieved from http://jama.jamanetwork.com.
69 - Ha, L., & Hauge, T. (2003). Percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in patients with stroke. Scandinavian Journal of Gastroenterology, 38(9), 962. DOI 10.1080/00365520310005190.
70 - Zopf, Y., Maiss, J., Konturek, P., Rabe, C., Hahn, E. G., & Schwab, D. (2011). Predictive factors of mortality after PEG insertion: Guidance for clinical practice. JPEN.Journal of Parenteral and Enteral Nutrition, 35(1), 50-55. DOI:10.1177/0148607110376197.
71 - Yokohama, S., Aoshima, M., Koyama, S., Hayashi, K., Shindo, J., & Maruyama, J. (2010). Possibility of oral feeding after induction of percutaneous endoscopic gastrostomy. Journal of Gastroenterology & Hepatology, 25(7), 1227-1231. DOI:10.1111/j.1440-1746.2009.06190.
72 - MacDougall, C. (2010). SASPEN Case Study: Nutrition in the ICU and multi-organ failure. South African Journal of Clinical Nutrition, 23(3):157-159. Retrieved from http://www.ajol.info/index.php/sajcn/article/view/59893.
73 - Codner, P. A. (2012). Enteral nutrition in the critically ill patient. Surgical Clinics of North America, 92(6), 1485-1501. DOI:10.1016/j.suc.2012.08.005.
74 - Heyland, D.K., Drover, J.W., Dhaliwal, R., & Greenwood, J. (2002). Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: Role of small bowel feeding. Journal of Parenteral and Enteral Nutrition, 26(6), 51-57. DOI: 10.1177/014860710202600608
75 - Sobani, Z., Ghaffar, S., & Ahmed, B. N. (2011). Comparison of outcomes of enteral feeding via nasogastric versus gastrostomy tubes in post operative patients with a principle diagnosis of squamous cell carcinoma of the oral cavity. Journal of the Pakistan Medical Association, 61(10), 1042-1045. Retrieved from http://ecommons.aku.edu/pakistan_fhs_mc_surg_otolaryngol_head_neck/12.
76 - Sheth C.H., Sharp S. & Walters E.R. (2013) Enteral feeding in head and neck cancer patients at a UK cancer centre. Journal of Human Nutrition and Dietetics, 26(5), 421-428. DOI:10.1111/jhn.12029
77 - Blomberg, J., Lagergren, P., Martin, L., Mattsson, F., & Lagergren, J. (2011). Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointestinal Endoscopy, 73(1), 29-36. DOI:10.1016/j.gie.2010.09.012.
78 - Keung, E. Z., Liu, X., Nuzhad, A., Rabinowits, G., & Patel, V. (2012). In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy. Journal of the American College of Surgeons, 215(6), 777-786. DOI:10.1016/j.jamcollsurg.2012.08.013.
79 - Sanders, D.S., Carter, M.J., D'Silva, J., James, G., Bolton, R.P., & Bardhan, K.D. (2000). Survival Analysis in Percutaneous Endoscopic Gastrostomy Feeding: A Worse Outcome in Patients with Dementia. The American Journal of Gastroenterology, 95(6), 1472-1475. DOI: 10.1016/S0002-9270(00)00871-6.
80 - Koretz, R. L., Avenell, A., Lipman, T. O., Braunschweig, C. L., & Milne, A. C. (2007). Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. American Journal of Gastroenterology, 102(2), 412-429. DOI:10.1111/j.1572-0241.2006.01024.
81 - Norman, K., Pitchard, C., Lochs, H., & Pirlich, M. (2008) Prognostic impact of disease-related malnutrition. Clinical Nutrition, 27, 5-15. DOI:10.1016/j.clnu.2007.10.007.
82 - Pear, S.M. (2007). Patient Risk Factors and Best Practices for Surgical Site Infection Prevention. Managing Infection Control. Accessed electronically from http://www.kchealthcare.com/media/1515/patient_risk_factors_best_practices_ssi.pdf on 07 July 2014
83 - Pratt, D.S. (2010). Liver chemistry and function tests. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia: Saunders Elsevier, chapter 73. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm
84 - Nair, R., Hertan, H., & Pitchumoni, C. S. (2000). Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. The American Journal of Gastroenterology, 95 (1), 133-136. DOI:10.1111/j.1572-0241.2000.01673.x.
85 - O'Mahony, S. (2012). Dif?culties with percutaneous endoscopic gastrostomy (PEG): a practical guide for the endoscopist. Irish Journal of Medical Science, 182, 25-28. DOI 10.1007/s11845-012-0845-2.
86 - Playford, D. (2010). Oral feeding dif?culties and dilemmas: a guide to practical care particularly towards the end of life. Advances in Clinical Neuroscience and Rehabilitation, 10 (3), 39-40.
87 - Tanswell, I., Barrett, D., Emm, C., Lycett, W., Charles, C., Evans, K., & Hearing, S. D. (2007). Assessment by a multidisciplinary clinical nutrition team before percutaneous endoscopic gastrostomy placement reduces early postprocedure mortality..Journal of Parenteral and Enteral Nutrition, 31(3), 205-211. DOI: 10.1177/0148607107031003205.
88 - Buscaglia, J.M. (2006). Common issues in PEG tubes- what every fellow should know. Gastrointestinal Endoscopy, 64 (6), 970-972. DOI:10.1016/j.gie.2006.07.042.
89 - DeLegge, M. H., McClave, S. A., DiSario, J. A., Baskin, W. N., Brown, R. D., Fang, J. C., & Ginsberg, G. G. (2005). Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy. Gastrointestinal Endoscopy, 62(6), 952-959. DOI:http://dx.doi.org.ezproxy.uct.ac.za/10.1016/j.gie.2005.08.024.
90 - Kurien, M., McAlindon, M. E., Westaby, D., & Sanders, D. S. (2010). Percutaneous endoscopic gastrostomy (PEG) feeding. BMJ: British Medical Journal (Overseas & Retired Doctors Edition), 340(7756), 1074-1078. DOI:10.1136/bmj.c2414.
91 - Daniel, K., Rhodes, R., Vitale, C., & Shega, J. (2014). American Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement. Journal of the American Geriatrics Society, 62, 1590-1593. DOI: 10.1111/jgs.12924.
92 - Jordan, S., Philpin, S., Warring, J., Cheung, W.Y., & Williams, J. (2006). Percutaneous endoscopic gastrostomies: the burden of treatment from a patient perspective. Journal of Advanced Nursing, 56(3), 270-281. DOI: 10.1111/j.1365-2648.2006.04006.x.
93 - Rogers, S.N., Thomson, R., O'Toole, P., & Lowe, D. (2007). Patients experience with long-term percutaneous endoscopic gastrostomy feeding following primary surgery for oral and oropharyngeal cancer. Oral Oncology, 43(5), 499-507. DOI:10.1016/j.oraloncology.2006.05.002.
94 - Brotherton, A., Abbott, J., & Aggett, P. (2006). The impact of percutaneous endoscopic gastrostomy feeding upon daily life in adults. Journal of Human Nutrition and Diet, 19, 355-367. Retrieved from http://web.b.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=1395252e-c7c2-4cb1-821d-ca78e8e674dd%40sessionmgr112&vid=0&hid=109.
95 - Anis, M.K., Abid, S., Jafri, W., Abbas, Z., Shah, H.A., Hamid, S., & Wasaya, R. (2006). Acceptability and outcomes of the Percutaneous Endoscopic Gastrostomy (PEG) tube placement- patients' and care givers' perspectives. Biomed Central Gastroenterology, 6(37). DOI:10.1186/1471-230X-6-37.
96 - Osborne, J.B., Collin, L.A., Posluns, E.C., Stokes, E.J., & Vandenbussche, K.A. (2012). The experience of head and neck cancer patients with a percutaneous endoscopic gastrostomy tube at a Canadian cancer center. Nutrition in Clinical Practice, 27(5), 661-668. DOI: 10.1177/0884533612457181.
97 - Brotherton, A., & Judd, P.A. (2007). Quality of life in adult enteral tube feeding patients. Journal of Human Nutrition and Diet, 20, 513-522. Retrieved from http://web.b.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=9fef6b68-b6a0-46a2-bf7f-9231ce6fcf3b%40sessionmgr198&vid=1&hid=109.
98 - Martin, L., Blomberg, J., & Lagergren, P. (2012). Patients' perspectives of living with a percutaneous endoscopic gastrostomy (PEG). Biomed Central Gastroenterology, 12, 126-134. Retrieved from http://web.b.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=e8e849fd-2b09-4ae2-bfc8-8900217edf23%40sessionmgr198&vid=0&hid=109
99 - Lin, L.C., Li, M.H., & Watson, A. (2011). A survey of the reasons patients do not chose percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) as a route for long-term feeding. Journal of Clinical Nursing, 20, 802-810. doi: 10.1111/j.1365-2702.2010.03541.x.
100 - Goldberg, L.S., & Altman, K.W. (2014). The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical Intervention in Aging, 9, 1733-1739. DOI.org/10.2147/CIA.S53153.
101 - Sampson, E.L., Candy, B., & Jones, L. (2009). Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews,2. DOI: 10.1002/14651858.CD007209.pub2.
102 - Naidoo, S. (2012). The South African national health insurance: a revolution in health-care delivery. Journal of Public Health, 34(1), pp. 149-150. DOI:10.1093/pubmed/fds008.
103 - Heyland, D.K., Cahill, N.E., Dhaliwal, R., Sun, X., Day, A.G., & McClave, A. (2010). Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a Multicenter Observational Study. Journal of Parenteral and Enteral Nutrition, 34, 675-684. DOI: 10.1177/014607110364843.
104 - Loser, C., Aschi, G., Hebuterne, X., MArthus-Vliegen, E.M.H., Muscaritoli, M., Niv, Y., Rollins, H., Singer, P., & Skelly, R.H. (2005). ESPEN guidelines on artificial enteral nutrition - Percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition, 24, 848-861. DOI: 10.1016/j.clnu.2005.06.013.
105 - Dev, R., Dalal, S., & Bruera, E. (2012). Is there a role for parenteral nutrition or hydration at the end of life? Current Opinion in Supportive and Palliative Care, 6(3), 365-370. DOI: 10.1097/SPC.0b013e328356ab4a.
106 - Stiles, E. (2013). Providing artificial nutrition and hydration in palliative care. Nursing Standard, 27(20), 35-42. Retrieved from http://web.a.ebscohost.com.ezproxy.uct.ac.za/ehost/pdfviewer/pdfviewer?sid=db9450ad-a4f4-45ad-8e1d-81850172d273%40sessionmgr4002&vid=0&hid=4206
107 - Byron, E., de Casterle, D., & Gastmans, C. (2012). 'Because we see them naked" - Nurses experiences in caring for hospitalised patients with dementia: Considering artificial nutrition and hydration (ANH). Bioethics, 26(6), 285-295. DOI:10.1111/j.1467-8519.2010.01875.
108 - Langmore, S., Krisciunas, G.P., Miloro, K.V., Evans, S. R., & Cheng, D.M. (2011). Does PEG Use Cause Dysphagia in Head and Neck Cancer Patients? Dysphagia, 27, 251-259. DOI 10.1007/s00455-011-9360-2.