Advice please: Withdrawal of feeding tube

[Clubsingr28, ASN, RN]

Hello Nurses,

I am having a serious personal inner struggle with a current issue at work. "Mrs. G" (who is 79) had a CVA last year with resultant hemiplegia & dysphagia. Subsequently she became a LTC resident of mine after her hospital stay. She came to us with a PEG and receives bolus feeds. She is cared for by CNAs and hoyered into a recliner where she watches TV, listens to her classical music and reads the paper on a daily basis. She is able to say a few words such as "yes, no, not now, oh, ok", etc. Actually just recently has been saying a few new words. She does not have dementia but her husband has been her medical POA. She was doing so well we had speech consult with her just last week and she passed her 1st swallow eval. with flying colors. (Mr. and Mrs. G are financially wealthy people, the opera, theater, and fine dining were a BIG part of Mrs. G's enjoyment in life)...

So, the VERY NEXT DAY, her husband, (the healthy one who lived at home) passed away. Her husband was her biggest advocate. I never even had the chance to tell him how well she did during the swallow eval, he would have been excited)-- Now her 2 sons, who have hardly been in to visit her now have medical POA. (One I'd never met because he admittedly has only been in once in the past year and the other one maybe 3-5 times over the past year)-

Well yesterday the came in to tell "Mrs. G" that her husband had passed away BUT when they arrived she was not feeling well. They asked me what was wrong and I told them she had a UTI- They talked between themselves a few minutes then asked if there was a doc they could speak to.. I responded yes then went to get her. 30 minutes later the MD came to me with tears in her eyes and handed me a new Advanced Directive and told me to D/C Mrs. G's TUBE FEED FORMULA AND that we would NOT be starting the MACROBID so NO TX FOR THE UTI EITHER.... then she said the sons want to put her on hospice.

1) Mrs. G- is not aware of any of this...

2) She was medically stable other than the UTI

3) She does have some quality of life, enjoys music, company, newspaper, etc..

4) She had JUST started eating small amt. during her eval- MD d/c'd speech consult too

Nurses I need your opinions, PLEASE, and ALL will be respected...

Thank you!!

Kelly, RN in NY

[Esme12, ASN, BSN, RN]

Wow...Wow...Wow....Do you have an ethics committee? Probably not being LTC. Wow.

Here is what I think. The POA is valid IF she has been rendered incompetent and unable to make decisions

Medical or health care power of attorney (POA). The medical POA is a legal document that designates an individual — referred to as your health care agent or proxy — to make medical decisions for you in the event that you're unable to do so.

It does not give them to right to supersede her decisions. Is she alert enough right now to say whether or not she understands what she needs and can sign a consent?

When Your Health Care Documents Take Effect

Your health care documents take effect if your doctor determines that you lack the ability -- often called the "capacity" -- to make your own health care decisions. Lacking capacity usually means that:

• you can't understand the nature and consequences of the health care choices that are available to you, and
  
• you are unable to communicate your own wishes for care, either orally, in writing, or through gestures.
  

Practically speaking, this means that if you are so ill or injured that you cannot express your health care wishes in any way, your documents will spring immediately into effect. If, however, there is some question about your ability to understand your treatment choices and communicate clearly, your doctor (with the input of your health care agent or close relatives) will decide whether it is time for your health care documents to become operative.

I am not that familiar with long term care. In the hospital I would go to risk management, my manager, and legal/ethics committee. If it was serious enough and I felt strong enough...I would file an disabled/elder abuse with the state....to open a file and get an advocate for her.

You have a responsibilty and a duty to protect and advocate for your patient....what a terrible spot to be in...((HUGS)) STUDENTS this is a very good example of an ethical dilemma.

[RNsRWe, ASN, RN]

Holy crud, everything Esme said and then some....get yourself in front of whoever can intercede here. No way I'd be taking those sons' POA as valid if the patient herself is competent! And she has not been deemed INcompetent, so....someone needs to step in here, fast, before Junior One and Junior Two do something stupid.

[Esme12, ASN, BSN, RN]

Holy crud, everything Esme said and then some....get yourself in front of whoever can intercede here. No way I'd be taking those sons' POA as valid if the patient herself is competent! And she has not been deemed INcompetent, so....someone needs to step in here, fast, before Junior One and Junior Two do something stupid.

You said what I was thinking...as usual I am trying to be diplomatic ...my brain however is always somewhat more indelicate in it's thoughts!

someone needs to step in here, fast, before Junior One and Junior Two do something stupid.

perfectly worded

[Esme12, ASN, BSN, RN]

This is going to bug me now...OP please come back and tell us how things are going

[kiszi, RN]

No way! It infuriates me when people misinterpret POA to mean they get to direct care for someone who is competent. That doc should never have allowed this to happen without involving the patient.

And just curious, what terminal diagnosis are they using to justify putting her on hospice? It seems that CVA in this case would not be enough.

I would have a word with the medical director on this one. The news media might be interested as well.

[RNsRWe, ASN, RN]

You said what I was thinking...as usual I am trying to be diplomatic ...my brain however is always somewhat more indelicate in it's thoughts!

Y'know, diplomacy absolutely has its place. But sometimes spelling out exactly what needs to be heard has its bonus points, too. No time to mince words with this one....really hope the OP can get something done (it's SUNDAY!).

[calivianya, BSN, RN]

If she passed her swallow eval, does it matter that the family d/ced tube feedings? The way we do swallow evals (hospital, not LTC) is that when they pass them, they get to eat. If she is capable of eating, what's the problem with stopping tube feeds? She can just eat instead.

I agree about them deciding against antibiotics, though... you do need to get the ethics committee involved!

[Esme12, ASN, BSN, RN]

Y'know, diplomacy absolutely has its place. But sometimes spelling out exactly what needs to be heard has its bonus points, too. No time to mince words with this one....really hope the OP can get something done (it's SUNDAY!).

Trust me I've ruffled feathers....LOL I can be very direct when the occasion arises...LOL Me I'd file an abuse report

[jschut, BSN, RN]

Oh wow... I agree with all of the above... Talk to the DON, the Medical Director... a health care POA is only viable if the person is not capable of making her own decisions... sounds to me as if she IS capable...

[Clovery]

Maybe the patient had expressed to her family she didn't want to be kept alive with feeding tubes and the husband allowed it because he was unable to let go? I'm disturbed by this too, just trying to look at it from another perspective. If she passed the first swallow eval, she could be sufficiently nourished with some thickened liquids and ensure pudding.

I definitely think you need to advocate for the patient and say that she was able to understand and communicate but the current UTI is affecting this ability. She should be treated for the UTI and then have a psych eval (or whatever they use) to determine if she is capable of making decisions for herself. Don't they need another physician to agree she is terminal before withdrawing life sustaining treatments and putting her on hospice? Go to your DON and Administrator with your concerns immediately.

[Clubsingr28, ASN, RN]

Esme,

I cannot thank you enough for your support and excellent resources advice. I am exploring EVERY option for my resident because no-matter what, I NEED to know that in the end I did everything in my power to do what is RIGHT and BEST for my resident.

This all happened at the end of my shift on Friday and I have NOT been able to stop thinking about it since. I've used this time to research the ethics and legalities of what is going on here. I cannot participate in, nor can I ignore what I feel is wrong). I have NEVER, in nearly 20 years of nursing, had to confront anything like this. As I said it hasn't left my mind, I even dreamt about this last night.

I will be back on the floor tomorrow morning. I am going to attempt a conversation with "Mrs. G" and assess her comprehension level and understanding of what I am saying. If I feel she is not "on board" (if I detect or determine this is NOT what SHE wants, (according to her boys "she would never want to live half paralyzed & on a feeding tube") I will 1st call her MD and express my understanding of my resident's wishes and tell her I feel we need to revisit this conversation WITH "Mrs. G" PRESENT.

(Also)

Thurs eve is when she started not feeling well so a UA and CXR was ordered on 11-7. Frid afternoon I received UA results/CXR was still pending when I left. (There was fear of aspiration pneumonia secondary to the swallow eval/feed- I called the day nurse yesterday & found out>CXR came back normal, so, I asked her to call the MD and ask if we could continue with small comfort feeds at the VERY least! (IF she is still able to swallow tomorrow, ?? My fear now is, with the morphine that has been ordered she may be too "out if it"). It is one thing to watch an untreated UTI turn into sepsis but another to watch someone starve to death. (Not that I am on board with not treating the UTI) I hope you know what I mean..

Again, thank you for your very informative response and for your support and understanding.