To the Editor: The article by Calver and colleagues on the use of gastrostomy tubes in older Western Australians raises important issues regarding decision making for gastrostomy tube insertion and ongoing care of gastrostomy-fed patients. Calver et al report a high incidence of readmissions within 1 year for gastrostomy tube replacement or gastrostomy-related complication (25%) and a high 1-year mortality rate (54%)1 Extrapolation of New South Wales data suggests that about 11 000 Australians rely on gastrostomy feeding at home as their sole source of nutrition and hydration.2

In NSW, about 2300 gastrostomy and jejunostomy procedures are performed each year in public health care facilities, for which about 60% of patients are discharged home. Of these patients, 40% require tube feeding for 2 or more years, and 11% for 5 or more years. In the financial year 2004–05, there were about 700 reported presentations to emergency departments of patients requiring percutaneous endoscopic gastrostomy tube replacement or experiencing tube-associated feeding complications (eg, stoma site infection, tube blockage, buried bumper syndrome, and diarrhoea related to tube feeding); 15% of these presentations resulted in ward admission.2

Many complications can be prevented or treated effectively in the community, provided that patients, carers and health professionals are adequately trained and supported, and that formula, consumables and equipment are affordable. Of particular concern are situations where patients who have multiple comorbidities and disabilities and who cannot advocate for themselves are discharged to nursing homes and group homes. The NSW Ombudsman reported the deaths of two people in 2006 as a result of poor management of their gastrostomy tube feeding and recommended that minimum care standards be introduced.3

Enteral nutrition is an orphan therapy, with no single professional group taking ownership of it. Hospitals release their responsibility when they discharge a patient, as the patient is no longer admitted, and there are limited community services to take over care. Patients are left to fend for themselves, resulting in poor outcomes. How a patient will manage tube feeding at home should be an important part of the decision-making process that occurs before a tube is inserted, rather than an afterthought. As the use of therapies that can be performed at home increases (eg, dialysis and enteral nutrition), there needs to be increased investment in community-based health services to support patients in caring for themselves at home. This will bring social and economic benefits to both patients and the health care system.