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Clinical Ethics Case Consultation class="textlight"Robert D. Orr

A family physician requested an ethics consultation on a hospitalized patient asking for advice about placement of a feeding tube in a patient 1 week after a stroke. The ethics consultant spoke with the physician, the patientıs family, and her bedside nurses. He reviewed the chart and saw the patient, then wrote the following consultation report:

Narrative
This 73 year-old white female developed multi-infarct dementia about 4 years ago, but remained quite functional (alert, responsive, ambulatory) with short-term memory loss, and was cared for by her children until she had an upper gastro-intestinal hemorrhage 3 months ago. After a few days in hospital, she went to a nursing home in the community where she settled in quite well, though she thought she was living in her daughterıs home. Seven days ago she suffered a large ischemic cerebrovascular accident (CVA). Initially she was unresponsive, and it was felt that she would not survive. However, in the past few days she has improved. She now opens her eyes, smiles, recognizes family, and has given 1-word responses at least twice. She remains totally paralyzed on her right side. A swallowing evaluation shows very poor function; she would likely be unable to take in adequate nutrition and hydration with oral feedings, and would be at risk of aspiration.

On admission her family requested limitation of treatment (Do Not Resuscitate, Do Not Intubate, Do Not Transfer to Intensive Care Unit) based on previous statements and her written Durable Power of Attorney for Health Care (DPA/HC). She initially received standard intravenous fluids, but when she began to improve, total parenteral nutrition (TPN) was begun as a temporary measure until a decision could be made about a feeding tube. Her family are contemplating foregoing tube feeding based on her previous wishes, but they and the careteam share some discomfort with this plan since she is still improving, and her ultimate level of function is uncertain.

The patient is awake, fixes and follows, smiles, and grips fingers on request, but she is unable to give consistent answers or head shakes or finger squeezes to 'yes or no' questions. Her 2 daughters live locally, and they have been in close communication with their 3 brothers from out of state. They report that the patient was a homemaker and a substitute elementary school teacher. They describe her as an active, feisty, talkative woman before her dementia. Her husband died 24 years ago and she subsequently lived with a male friend for many years. He died about 4 years ago. She signed her DPA/HC nearly 5 years ago, before she began to deteriorate. In it she named one daughter as her agent, and left instructions requesting no aggressive treatment, including no feeding tube, if she were to become (1) permanently unconscious, (2) terminally ill, or (3) when the burdens of continued treatment exceeded the benefits. In addition, she expressed verbally to her children that she did not want to be a burden, did not want to survive 'as a vegetable', did not want to be kept alive by artificial means, and did not want to live in a nursing home. Of note in her family history is that her father died at age 74 after his 3rd CVA, and her sister has been in a nursing home, disabled from a CVA, for the past 11 years. The patient was a member of the Church of the Nazerene as a young adult, but has not attended church for many years.

Assessment
This woman is unable to make decisions but has left instructions about her treatment wishes. Her family are uncertain how to interpret her wishes in light of her uncertain prognosis.

Discussion
The previously expressed wishes of a patient should almost always be honored by her caregivers. It is very important in honoring them, however, to have a clear understanding and interpretation of their applicability. It is ethically permissible to withhold treatment which might postpone death for a particular patient, if it is felt that the maximal function or quality of life that she can attain is below a threshold that she would find acceptable.

Most healthcare professionals consider artificially administered fluids and nutrition to be medical treatment, thus subject to the same degree of discretion as other standard treatments. A minority maintain that fluids and nutrition, even if they cannot be taken orally, are morally obligatory.

In this case, the patient specifically said she would not want a feeding tube in several circumstances. The important question is whether she is currently in one of those circumstances. It might be argued that she is 'terminally ill' because she is likely to die in the foreseeable future of cerebrovascular disease or its complications. However, with continued treatment, she might survive for some time and might find her quality of life acceptable. Some might also argue that the burdens of tube feedings are greater than the benefits of continued life in this severely disabled patient. This contention is difficult to defend since gastrostomy tubes are generally felt to represent low-burden therapy, although they do often require hand restraints. In addition, this patient has adjusted to nursing home care which she had previously thought would be unacceptable, so it may be that dementia has changed her values.

Recommendations
In light of the uncertainties of interpretation of her wishes and of her prognosis, the following treatment options would be ethically permissible:

(1) If her professional caregivers believe there is insufficient chance of improvement to a level of function which her family believes she would find satisfactory, it would be permissible to stop TPN, not use tube feedings, and allow her to eat and drink if she wishes, recognizing this might not provide sufficient fluids and nutrition for long-term survival. Then comfort would be the primary goal of continued therapy. If she should aspirate, it would be acceptable to either use or not use antibiotics.

(2) If her family believes she would choose to have adequate fluids and nutrition until her neurologic prognosis is more certain, it would be permissible to continue a short term trial of TPN (for a few days) or institute a trial of tube feedings (for a few weeks). If she failed to improve sufficiently, this treatment could then be stopped and comfort care continued.

Follow-Up
The patient's TPN was continued for another 3 days during which she improved sufficiently to be able to swallow. She was discharged back to the nursing home with plans for comfort care and limitation of treatment, including no aggressive treatments and no re-admission to the hospital unless required for her comfort.

Six weeks later, the patient was maintaining adequate nutrition and hydration by mouth. She had experienced little further improvement in her neurologic condition. She was awake and smiled frequently, recognized her daughters, but was unable to speak. Her family and professional caregivers were satisfied with the process of decision-making and also with the outcome.- E&M

Robert D. Orr, MD, CM, Director of Ethics Fletcher Allen Health Care and the University of Vermont and Director of Clinical Ethics at The Center for Bioethics and Human Dignity.

This article appeared in Volume 18:1 of Ethics & Medicine.