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To PEG or Not to PEG A Case of a Hospice Referral for Vitamin B12 Deficiency

This case history of a 92-year-old patient with pernicious anemia and Alzheimer's dementia is an example of an inappropriate hospice referral as a result of the unfortunately all-too-common practice of making such referrals based on apparent clinical deterioration of elderly patients without proper physician diagnostic involvement to rule out reversible pathology. It further demonstrates the benefit of home tube feedings utilizing percutaneous gastrostomy in dementia patients with malnutrition due to swallowing dysfunction without aspiration and without evidence of malabsorption syndrome. The prevailing “prejudice” against recognizing the benefits of tube feeding of the non-terminal elderly on the part of both families and clinicians is a “hurdle” that can be overcome with gentle, persistent patient advocacy and a touch of “paternalism” in the face of the “modern” medical-moral culture of equating “substituted judgment” with “absolute autonomy.” This case also demonstrates the need to evaluate each patient on a rational, individual, clinical basis as opposed to blindly applying so-called “evidence-based medicine” in an extremely diverse population of patients labeled with the so-called diagnosis of “terminal Alzheimer's dementia.”