Swallowing Difficulty and Speech Difficulty on Quality of Life in Patients with PEG Tubes vs. Those on NGT Feeding Systems
Stroke can effect neurological functioning and can have an effect on the patient's ability to talk and swallow. This condition can lead to severe malnutrition A decision is often made to feed the patient using a tube feeding method. Many studies have been performed to measure the clinical outcomes of these procedures, but few have focused on the effects of the patient's quality of life after receiving these interventions. This study will measure the effects of having a PEG tube inserted on the patient's quality of life as it relates to their ability to communicate and swallow. Two research questions will be answered: "Does a PEG procedure have an effect on the patient's ability to communicate their wishes and improve there satisfaction with the quality of their life in regards to self-care?" And "Does the PEG method offer more satisfaction in regards to quality of life than the NGT method?"
The Effects of Swallowing Difficulty and Speech Difficulty on Quality of Life in Patients with PEG Tubes
There are two primary methods for administering food to patients who can no longer swallow or have difficulty swallowing. The first is by way of an NGT tube, which is inserted through the nasal cavity and goes into the stomach. This procedure severely limits the patient's ability to speak or swallow. The other popular method is PEG where a tube is inserted through an incision in the abdominal wall. In this case a patient's ability is speak or swallow is not limited by the procedure itself. However, in stroke patients this ability may already be impaired. Many of us consider the ability to communicate our own wishes and enjoy conversation with other human beings a factor in determining our quality of life. Being unable to communicate with another creates a feeling of isolation or helplessness.
The PEG tube is inserted through an incision and provides liquid food to the patient if they are unable to maintain nutrition through normal means due to a difficulty in swallowing. Tube feeding is considered a medical intervention and is not obligatory care (Taylor, 2001). Percutaneous Endoscopic Gastrostomy (PEG) was first used in 1979. It is becoming standard procedure in many clinical settings. It is considered safe and only requires local and IV anesthesia (Taylor, 2001). Although it is relatively simple, there have been many issues arising from its use.
PEG feeding is typically used in patients with a neuromuscular disorders, including stroke, and cancer. Many of these studies have centered on the effectiveness of the PEG procedure in preventing malnutrition and improving patient outcomes. One of these studies was conducted by James and associates (1998) and looked specifically at a group of patients following PEG placement after dysphagic stroke. Little data is available about tube placement and adverse events after placement (Taylor, 2001). Many of the studies, which have been conducted, have been inconclusive or did not draw a definitive correlation between PEG feeding and patient survival or improvement. Therefore, the effectiveness of the procedure itself must be questioned. Most studies involving this technique have focused on clinical outcomes and have not considered the psychological and comfort levels of the patients from the patient's perspective.
These patients may exhibit swallowing difficulties, particularly failure to manage the food properly once it is in the mouth, called oral phase dysphagia. Or a patient may demonstrate Pharyngeal phase dysphagia, in other words, they may aspirate when swallowing. PEG feeding is used in these patients to prevent aspiration pneumonia, prevent malnutrition and provide comfort. As clinical evidence on the usefulness of this technique is questionable at best, as indicated by a review of clinical studies (Taylor, 2001), we must then focus our attention on the patient comfort issue.
The term "quality of life" means different things to different people. Many of us would agree that whatever means we use to determine our level of quality of life, it is an important factor in the decisions that we make. When faced with a life threatening or debilitating illness we must make many decisions regarding the procedures used and their effect on the quality of life.
For Dysphagia stroke patients a large part of their recovery focuses on regaining basic functions of life. One of the goals in therapy is to regain the ability to speak and swallow. The NGT makes it difficult to perform the therapy to regain these functions. The PEG tube should help allow the person to regain these functions more quickly, thus improving their perceived quality of life.
This study will focus on the use of the NGT method and the PEG feeding tube methods. It will determine which one has the greatest effect on the patient's quality of life as far as the ability to regain swallowing and speaking ability is concerned. Finucane and associates (1999) discussed PEG feeding in patients with dementia. This study will focus on patients who have dysphagia as a result of stroke. Many of these patients exhibit the same difficulties as the patient population described in Finucane's study (Finucane, et. al. 1999)
This study will focus on determining the quality of life, with regards to the patient's ability to regain speech and swallowing ability with the use of the two feeding tube methods, NGT and PEG. It will support the theory that the PEG tube method will provide the patients with an improved quality of life, as measured by their ability to undergo therapy to regain their ability to speak and swallow. It will be determined through the use of a survey measuring their quality of life and their ability to undergo therapy to regain their swallowing and communication ability.
The sample will consist of 25 PEG patients and 25 NGT patients who are long-term care dysphagic patients at local hospitals and long-term care facilities. The survey will be administered verbally, with an assistant recording the results in cases where the patient has impaired ability to fill out the survey themselves. The assistant will read the questionnaire and mark the answer indicated by the patient. This sample of patients will be limited in their ability to answer and therefore they will need assistance in completing the survey. They will be screened for mental functioning through staff interviews, as personal information regarding specific patients is not available due to the Right to Privacy Act. The patients selected will be of normal mental functioning, but will have limited ability to speak or swallow due to a stroke. In addition, they will be fed either by NGT or PEG method. The survey results of the two groups will be compared. It is expected that the group receiving PEG feeding will have a higher satisfaction with their quality of life than those on NGT feeding.
The control group will consist of those on NGT feeding systems and the dependent variable will consist of those on the PEG feeding system. They will be administered the same survey and will receive a point for each positive "Quality of life" question. A scale will be developed to determine the range of scores for high, moderate and low satisfaction with the quality of life. As these patients will be limited in communication skills, the questions will be yes or no so that non-verbal signals can be easily used.
This study design was chosen as the purpose is to compare the survey results of one group directly to those of another group. It is expected that a direct correlation will be found between a better satisfaction with a patient's quality of life and the presence of the PEG feeding system as opposed to the NGT feeding system. It is expected that those with the NGT feeding system will give lower satisfaction scores than PEG patients. Questions will be designed to be easy to administer to the patients. Most questions will begin, "Do you feel... " and will require a yes or no response that can be written on the form by the patient themselves or the assistant where needed. Answers that are giving a positive indication of satisfaction will receive 1 point, whereas the negative answer will receive no points. The number of points will be compared to a scale to determine that level of satisfaction with quality of life that tone has concerning the type of feeding method used and the ability to regain communication and swallowing ability. The scale will be divided into "high satisfaction," moderate satisfaction," and "low satisfaction."
Data will be analyzed by first determining where the majority of answers lie within the dependent (NGT) and independent variable (PEG). These will be analyzed using descriptive statistical methods, mean, median, mode, frequency distribution and standard deviation. The two groups will then be analyzed to determine that they are indeed statistically different using z-test and a p-value of 0.05. It is expected that the two groups will be statistically different and that…