Wednesday, May 6, 2015
Case 27 Nutrition (12May)
Answer the questions at the end of the case, using a theory you didn't use in the other case study (about changing a DNR). Collectively, you should cover all of the theories we've read about (Kant, Virtue Ethics, Act Utilitarianism, Rule Utilitarianism, Principles of Bioethics, Ross' Principles, Ethics of Care, Casuistry, & Reflective Equilibrium). Feel free to (gently) correct each other if necessary. :)
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Mildred does not want resuscitated but that doesn't mean starved, unless otherwise stated on her living will. Most people who have a DNR living will want to be comfortable. Nutrition can be construed as a form of comfort. With this understanding it is not morally acceptable to withhold nutrition in this situation. The Patient, family, and the Dr are aware of the Patient's wishes so ethically the family does not have the right to make that decision for the Patient and the Dr can object and override that decision.
ReplyDeleteI used W.D. Ross's Theory with regards to the Dr's actions. The Dr. used the Duties of Beneficence, for Mildred's welfare and preventing discomfort, and the Duties of Justice keeping her prior wishes upheld. If discomfort causes harm, and we should avoid harm, then the Duties of Nonmaleficence would also apply. I think the Dr. was morally right in his decisions.
Most of the patient's that I encounter with "comfort measures" end up having their NG removed and do not get nutrition. They are kept comfortable with medications. I can see where nutrition would be a comfort measure though. On my unit, by the time comfort measures are decided, the patient no longer requires a cardiac monitor and is usually transferred to a med/surg unit.
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DeleteIf the patient is provided palliative care to provide comfort, I believe that the family should abide by the patient's request. The quality of life is essential to remember not the quantity.
DeleteJodi that is a great comment the quality of life is essential not the quantity in years. So so true especially in this situation.
DeleteI also look at the diving bell and the butterfly with regards to a stroke. Who knows what goes on when someone has been paralyzed and is in a coma. I still stick with my ideas about comfort and nutrition. Even if it's trickle feedings. But I also think that the family should make this decision after they are educated. They are the only ones who know their mother and what she would want.
DeleteIt sounds like Mildred only has a DNR order and not a living will. If she had a living will she could have indicated that she did not want artificial means of nutrition. If a patient is not able to make decisions on their own do not have a living will, then their next of kin or POA could make the decision to withhold food and make the patient hospice. An NG tube would only be the temporary route for nutrition. The family would have to consent to a PEG placement, which by reading this case it seems they would not be agreeable to. In this case, I believe it is morally legitimate to withhold nutrition. I think in this case Rule Utilitarianism comes into play. I believe the act of withholding nutrition would lead to the greater good for the patient and family.
ReplyDeleteI completely agree with you Sarah. I believe they should in this case go to the POA for advice and decision for care. After reading the case I don't feel that this family would consent to a PEG tube and I feel that prolonging Mildred's life would only produce more issues such as bed sores, pneumonia, and hospital acquired infections.
Deletei used Ross' principle of nonmaleficence in my consideration of this case. It appears this patient just has a DNR and it is right to let the family decide what course to take with regards to withholding the tube feedings, as long as the reasons to withhold or continue treatment are explained as completely as possible. It could be harmful to continue by causing malnutrition and eventually pressure ulcers and extreme discomfort, whereas a human's dying experience, good or bad, can be controlled to an extent.
ReplyDeleteI also believe the family should be thoroughly educated on the pros and cons so they can make an educated decision that is in the best interest of the patient.
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DeleteI thought this was a good case study becuase I feel like we encounter this alot. pt's have DNR thinking they have covered everything that can happen but they forget about tube feedings. I also believe education needs to be discussed to family in tryng to make this decision. I feel like the dr should discuss his concerns about witholing the nutrition with the family but the decision is up to them to make not the md.
DeleteI agree ! I believe that the physicians tend to struggle with educating the patient and the family about the disease process, prognosis, and expected outcomes. I feel as if the family was provided the education needed, they would have a better upstanding and grant the wishes of the patient.
DeleteI also agree physicians tend to struggle with educating the family about disease process, prognosis, and expected outcomes. In this case the patient had a DNR order. But nothing else stating what she would want her life to be like if her condition was to change her way of lfe. If more information was given to the patient in the beganing she could have explored more decision making.
DeleteI agree Jodi about the physicians struggling to give information to patients and their families about what will happen on the way to the end of life. I think we like to assume the Drs. should be informing them but at the same time it must be extremely difficult. I often wonder if they (the MD's) feel like they are admitting failure. It is so hard to truly give informed consent-even for a stress test. How many of our patients don't even read the consents? On occasion I have had patients read it (one even read it aloud) and they are surprised to read that it is a possibility of death.
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ReplyDeleteLooking at this from a virtual ethics standpoint, I do not believe it is ethical to withhold nutrition. Virtual Ethics asks "what kind of person should I be"? I do not think a moral person would opt to starve someone so they would die sooner. If her medical condition is that severe, I do not think withholding her nutrition would cause her to die sooner than the other. Chances are she would suffer even more with starving due to hunger, possible sepsis from breakdown, and pain itself from pressure ulcers among other things. One of the virtues is to exercise rationality, and in this case it is rational to feed their mom to promote comfort while she is in the dying process. I do believe however, the family has the right to make this decision. I feel they know their mom the best and may know how she feels about this issue to make the best decision for her and her family. Even if we disagree, we have to be impartial at times. I feel the refusal of resuscitation is a very strong indicator that the patient may refuse nutrition. Especially if she is semi-comatose, unable to eat or feed herself, she probably would not want to live this way if there was not reasonable hope for a recovery.
ReplyDeleteI agree Carla! With all your rationale. The family should be able to make an educated request on their mom's behalf. Usually the Dr. only orders minimal tube feedings and yes with the NG tube it is temporary but it is comfort in my minds eye.
DeleteWorking in Hospice I see all too often that people struggle with the thought of their loved on dying from starving to death. We often see patient die from complications from aspiration pneumonia when a family wants to keep feeding them whether it be the conventional by mouth or by NG/peg tube feeding.
DeleteIn the case of Mildred, I think it is morally legitimate to withhold nutrition. Mildred had a DNR in place which makes me think she did not want any life sustaining measures, and in this case food would be life sustaining. I believe her family has the right to make that decision if they are all in agreement. She is unable to make her own decision, and hopefully told her children her wishes. I think Kant comes into play in this case of ethics of respect for persons and virtue of humanity and inherent dignity. I feel her children would be respecting her, not killing her withholding nutrition.
ReplyDeleteTricia I agree. I feel like her children knew what she wanted to have done and they are respecting her wishes bu wanting to have the nutrition to stop. what kind of quality of life is mildred having. By continuing feeding her we are only making her suffer longer, bed sores, aspiration pneumonia etc.
DeleteI agree Tricia. I don't think the family is wrong in withholding the nutrition. I don't think nutrition is important when close to death. She had verbalized her feelings to her family. It is there responsibility to uphold her wishes.
DeleteI agree Tricia. I don't think the family is wrong in withholding the nutrition. I don't think nutrition is important when close to death. She had verbalized her feelings to her family. It is there responsibility to uphold her wishes.
DeleteI had not really thought about possible adverse reactions to tube feedings. I think many times it is more difficult for family to actually stop nutrition. My parents had decided they would not withhold fluids at the end. When my mother's IV went bad, it was an excruciating decision for my dad as to if he should allow the nurse to attempt another IV. He gave them "one chance". They got it and she continued with the 5 or 10cc/hr-I know for HIM not her. I found that very compassionate.
DeleteI don't think that it is morally wrong for the family to want to stop the nutrition. The patient does have a DNR which is an indicater that she didn't want any extra ordinary means to be kept alive.I believe that keeping her fed so that her body can be kept alive is something that she woul not have wanted. Mildred is not her normal self and is indicated that she will never return back to her baseline. She only has an ng tube and would soon need to have a peg tube placed. Would mildred have wanted to go through a surgery to have something like this done so that she be kept fed? Would she even survive the surgery to place the peg tube. It states that she is semicomotose and paralyzed, her spirt( or old self) has already died. I believe the family has every right to request the feedings to stop. I believe that act-Utilitarianism would be the therory I use for this. Ending the suffering of Mildred by not feeding her would be the greater good. Even though her family would suffer by her death they would find relief in knowing that she isn't suffering anymore.
ReplyDeleteI agree that a person should not have to go through a surgery for PEG placement just to prolong a life that she would not be actually "living". I see nothing wrong if her family decides against feedings and promotes comfort measures only. The should not be a decision for the doctor to make or criticize.
DeleteI think the medical professionals should consider withholding her feedings through the NG tube and address her comfort as needed. Mildred has verbalized her wishes to her children and she was diagnosed with a medical condition that she will not improve. She relies on medical staff, equipment, and supplies to prolong her life. Using the utilitarian concept, something that is held to be good in itself, apart from further consequences, and all other values are believed to derive a intrinsic good as a means to an end. The act to hold Mildred’s feedings may not sound morally correct but the action would grant her wishes that she has verbalized to her children.
ReplyDeleteI also agree. Mildred had a DNR in place so she did not want to be kept alive with tubes and medical equipment. I think her children have to right to make that decision.
DeleteIt sounds like Mildred has a DNR status but not a living will. I do not think it is morally wrong to withhold her tube feedings if her wishes were to not continue life in this type of situation. In this I would talk to the next to kin or husband for decision making since this person would know what the patient wants and wishes are. I feel the theory of Utilitarianism would fit this situation well. Ending the feedings and care would be the better act for Mildred at this time. The good would out way the bad.
ReplyDeleteI agree Utilitarianism fits this situation. Mildred signed a DNR order so she had thought about her care and what she would want. In saying that talking to her husband or next of kin should be the one to help make the decision.
DeleteI think in this situation the doctor used his personal beliefs and feelings saying it was unethical to "starve her to death". Was it an accurate statement to say that she would starve to death vs her disease process would take her? I am not convinced that all physicians are comfortable with helping someone make these decisions. There is little evidence that nutrition is a benefit for someone at the EOL. In some cases can cause more harm such as N/V when the digestive system starts to shut down and the body no longer absorbs the feedings.
ReplyDeleteWhat I view as comfort measures someone else may not view the same. It is necessary to have hydration and nutrition to help someone get better and heal. It is not necessary to make someone comfortable in there journey towards end of life.
I believe it is morally legitimate to withhold nutrition in this case. I would use Utilitarianism to say that everyone's interest, patient and family, was considered. The patient's quality of life is not measurable in this capacity. Nutrition is given to the body to support, heal, and strengthen, however in conditions such as these, the body is not using the nutrition for its natural purpose. The family certainly has the legal right to make these decisions, if not previously stated in an advanced directive created by the patient. I feel like refusing resuscitation is the same as refusing nutrition. If you are refusing life saving, life-lengthening measures through a DNR status, then lengthening you life by artificial nutrition is not coinciding with your wishes.
ReplyDeleteI agree that in this case it is the nutrition that is keeping her alive- thus lengthening her life artificially, just as if a vent would. As Mildred further declines, even this may cause complications as we all know as nurse that NG tube feeding can only be used as a short term. Inserting a more permanent tube such as a PEG would only cause Mildred more pain at this point.
DeleteThere are times when a person may state that in a particular situation, they do not want "heroic, resuscitated or coded". In the event of a heart attack or stroke I believe those same people think it is a single event. That the event itself with either cause death or require the need to measures that may be viewed as extraordinary. What the general public may not be well versed are all the small steps that are taken to keep from needing the resuscitation. Mrs. D. for instance stated she did not want to be resuscitated, however she may have not had the knowledge that her children would have to make many other decisions about her care without her ever being resuscitated. I would like to discuss the ethics of casuistry. I am going to assume the physician and caregivers are not wanting to give nutrition to cause pain or prolong any suffering. What is not mentioned is how long she has been semi-comatose. fi this is new event it may be possible that the physicians want to see if there will be any improvement and give her the chance to have a better outcome than expected. Using the same theory of casuistry, I am going to state that her children have her very best interest in mind and heart. That they see the administration of nutrition as going against her wishes. The idea of not being able to do for their mother what they believe are her wishes means that both sides (physician and children) are each right. In a perfect situation what should happen is some honest open communication between family and physician, possibly with a third party to act as an 'interpreter' of medical terms and with a knowledge of interpersonal relationships to help both parties recognize the other has the best interest of the patient in mind.
ReplyDeleteYour ideas bring up a good topic. Usually when there is a conflict of interest with the family and the medical team, like whether to feed or not, we put together a family meeting with a social worker, the family, and the Physicians. I say Physicians because we like the primary care physician and the Intensivist to be present so the continuity of care flows and everyone is on the same page with regards to concerns and the Patient's care. From this meeting comes a plan or a goal. The Patient and family's needs are met along with the Dr.s concerns. After the meeting I usually discuss with the family verifying what was decided to make sure that they understood what was said through the entire meeting. Time and empathetic communication help the coping process for the family and the Patient during this trying time.
ReplyDeleteYour ideas bring up a good topic. Usually when there is a conflict of interest with the family and the medical team, like whether to feed or not, we put together a family meeting with a social worker, the family, and the Physicians. I say Physicians because we like the primary care physician and the Intensivist to be present so the continuity of care flows and everyone is on the same page with regards to concerns and the Patient's care. From this meeting comes a plan or a goal. The Patient and family's needs are met along with the Dr.s concerns. After the meeting I usually discuss with the family verifying what was decided to make sure that they understood what was said through the entire meeting. Time and empathetic communication help the coping process for the family and the Patient during this trying time.
ReplyDeleteThis is a difficult case study. With the information provided, I would not continue the tube feedings. Mildred has told her family in the past that she does not wish to be resuscitated. We are told that a substantial portion of her brain has been destroyed and she is semi comatose. As the body shuts down and goes through the dying process the GI tract will not be able to process the tube feed and it may cause more complications and discomfort than not initiating them in the first place. I do not believe it is unethical to withhold nutrition in this case. I believe that the family should be able to make the decision for their mother as I believe they would know her wishes better than the physician. I consider the fact the she had communicated with them regarding resuscitation an indicator that she would also refuse nutrition. I used Rule Utilitarianism as I believe it minimizes pain and suffering of the patient and family.
ReplyDeleteCindy I agree. It would be best to not go on with the tube feedings. I believe if the family does so, they could be doing more harm than good in this case. I think the family should focus on making their mother as comfortable as possible during this time.
DeleteI agree. I do not believe having a tube and forced feedings would be comfortable.
DeleteMildred D. had an DNR order so in saying that I feel she would not want to be living on tube feedings. I know that DNR order does not cover tube feeding removable but it does show that Mildred did not want to be living on life support. In this case the tube feedings is the same as a vent. Without it she will die. I feel in this case the family does have the right to make the decision. They should be educated and prepared for the choice that they are making for their loved one.
ReplyDeleteI completely agree with your reference to the vent. If a patient is on a vent and did not have a DNI order it would be up to the family to remove the vent. The same applies to the artificial feedings, it is up to the family to decide if the patient cannot.
DeleteI believe in this case that morally nutrition can be withheld and if the living will did not specify then it would be the decision of the family to decide. An NG tube can not be used for long term supplemental feedings so it will be the families decision on whether or not to place a PEG tube and I feel they can chose against that if they wish.
ReplyDeleteUsually if a person has already had a living will written up of made the decision of DNR status without having a legal document they have discussed their wishes at some point with their family. I don't think the refusal of resuscitation would be considered an indicator that the patient would also refuse nutrition, but if the patient cannot make that decision then the family can.
I agree that most families have " the talk " at some point in their lives, I know my family and I have - without pursuing the legal documentation. Most family's are capable of making these decisions for their loved ones if they have been well informed of the situation by the physician.
DeleteI agree that they could have had a better talk. I think putting her through a peg tube would be extreme. The family seems to be at an agreement which makes me think that they do have a good idea of what she would want for herself.
DeleteThis is a situation often seen in the healthcare setting. A critical unforeseen event that catches a patient and family by surprise , without the legal backing to make decisions cut and dry. In this case , I think it is morally legitimate to withhold nutrition. Mildred has little to no chance of recovery and her situation is terminal. It is reasonable to consider the wishes expressed by her family as her own, as many families talk about the " what if's" unfortunately without pursuing the legal documentation. I think the family does have a right to intervene in this case , as they know Mildred best. Using the principles of bioethics, we could justify this statement by considering the principle of nonmaleficence - perhaps the family feels that they are dong Mildred MORE harm by prolonging her life in this case, especially snce she has expressed to them that she would not want to be resuscitated were her situation dire.
ReplyDeleteI agree totally. I do believe also that the family may feel that they are doing more harm than good by starting tube feedings.
DeleteI believe that Mildred would not want to have the feedings. She has a DNR so I believe that is an sign that she did not want her life prolonged by artificial means. Artificial means of feeding such as PEG tubes can sometimes cause more harm than good, such as N/V or serve diarrhea that could also lead to skin breakdown and pressure ulcers. I think the doctor should sit down with the family members and go over each prop and con of tube feeding. The family knows that patient better than anybody and they will have a better idea as what the patient would want.
ReplyDeleteThe doctor told the patient's family that they should not let her starve to death. Because of this statement I think that the family may end up having the feeding tube placed for the wrong reasons, just as Kant talked about. The family could be doing the right thing for the wrong reasons, not because they feel that is what she would of wants but due to the statement that the doctor had said.
This is so true. The skin breakdown would only lead to more infections. Chances are she will end up with bed sores, since she is unable to move. In this case tube feeds would not be in the best interest for Mildred.
DeleteIt is morally legitimate to withhold nutrition. With Mildred's history and amount of damage to her brain the chances are she would not starve. Depending on how her body is compensating the digesting of the nutrition could also cause discomfort. Patient's on tube feed also usually has frequent loose stools that could cause her skin break down and additional pain. The family does have the right to make decisions for Mildred's care. They seem to have a good idea of what she wants and have her best interest at heart. When they discussed becoming a DNR they could have furthered that discussion by talking about artificial means of life prolonging treatments.
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