Indications for PEG insertion (as per PEG guidelines) CVA Motor Neurone Disease Poor nutritional Status Multiple sclerosis Trauma Head and Neck Cancer Dysphagia Pre radiotherapy/pre surgery Learning disabilities Anorexia or Cachexia Obstructive lesion oesophagus Other please specify – Reason for PEG referral: Home circumstances Have social and domestic circumstances been investigated? If no, investigation into home circumstances should be Are they satisfactory for tube feeding at home? undertaken. If potential difficulties are identified, consider Yes/No MDT/best interest meeting. Signed: Designation: Date: Is the patient capable of undertaking care of the feeding tube If no, determine/consider other options. independently? Comments: Yes/No Signed: Designation: Date: Are family members or informal carers available to manage If no, determine/consider other options. tube feeding if required? Comments: Yes/No Signed: Designation: Date: Has a care agency been identified to care for the tube feeding If no, liaise with social workers to identify appropriate care (if required)? agency to create care package, or if needed consideration should be given to a nursing home. Yes/No Please contact dignitary matron where appropriate. N/A Comments: Signed: Designation: Date: Are arrangements in place regarding training for If no, arrangements need to be made for patient/family/carers to patient/family/carers on administering feed and medications via receive this training. the tube? Yes/No Signed: Designation: Date:
Home circumstances Have social and domestic circumstances been investigated? Are they satisfactory for tube feeding at home? Yes/No Signed: Designation: Date: If no, investigation into home circumstances should be undertaken. If potential difficulties are identified, consider MDT/best interest meeting. Is the patient capable of undertaking care of the feeding tube independently? Yes/No Signed: Designation: Date: If no, determine/consider other options. Comments: Are family members or informal carers available to manage tube feeding if required? Yes/No Signed: Designation: Date: If no, determine/consider other options. Comments: Has a care agency been identified to care for the tube feeding (if required)? Yes/No N/A Signed: Designation: Date: If no, liaise with social workers to identify appropriate care agency to create care package, or if needed consideration should be given to a nursing home. Please contact dignitary matron where appropriate. Comments: Are arrangements in place regarding training for patient/family/carers on administering feed and medications via the tube? Yes/No Signed: Designation: Date: If no, arrangements need to be made for patient/family/carers to receive this training. Indications for PEG insertion (as per PEG guidelines) CVA Motor Neurone Disease Poor nutritional Status Multiple sclerosis Trauma Head and Neck Cancer Dysphagia Pre radiotherapy/pre surgery Learning disabilities Anorexia or Cachexia Obstructive lesion oesophagus Other – please specify Reason for PEG referral:
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