Advice please: Withdrawal of feeding tube

Nurses General Nursing

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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

Specializes in Sub-acute, LTC, School Nurse.

The problem is this: The resident was to be working with the speech/swallow evaluator x's 4 weeks of which she only had one day (which the evaluator said she did excellent) but it was just the 1 day. The resident was not assessed long enough nor has nursing been given the OK for this resident to safely be fed by staff...hence the problem

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I would need official paper work that they are the POA. I think they need to understand that she isn't dying...yet. They seem awfully anxious for her demise. Realism in one thing...hastening is another. I'd call social services.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

[h=3]Long Term Care (LTC) Ombudsman[/h] State LTC ombudsman programs investigate and resolve nursing home complaints, and in some areas, complaints about board and care facilities and professional home care providers. If you are concerned about abuses, check the state Long Term Care Ombudsman exitdisclaimer.gif program in your area for help.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

here is a guide to the states ombudsman http://www.ltcombudsman.org/ombudsman

Specializes in MDS/ UR.

I'd be calling everyone and their mother.

Specializes in SICU, trauma, neuro.

Wow. I am almost without words. But I'll figure some out.

Years ago when I was a CNA in LTC, we had a resident who was not actively dying; he was taking 100% of his nutrition PO, and even had some impressive muscle tone for someone who was non-ambulatory. He *looked* healthy. His wife at one point refused antibiotics for a UTI because she didn't want to "prolong his life." My facility did have an ethics committee which convened on this issue. 1) he wasn't dying, 2) DNR =/= do not treat, 3) at best, letting someone be in pain from a UTI is cruel, and 4) allowing him to die of urosepsis would be unspeakably cruel.

I thought of this gentleman when reading your post. I would have issues even if someone WAS on hospice and dying, with not treating a UTI because UTIs are so painful. It feels like urinating shards of glass! Treating a UTI, in my humble opinion, would be a comfort measure.

Esme gave some great resources, which I encourage you to avail yourself of *forthwithal* (my word of choice when "immediately" or even "yesterday" just isn't strong enough.)

This woman is not dying. If nothing else she needs as complete a speech eval as she needs to be able to take PO, if she passed her swallow eval but hasn't been officially given the order to take PO. Withdrawal of tubefeedings is a debatable ethical issue (is it life-sustaining treatment, or is it food? Are you letting the disease take its natural course, or are you starving a person?)...BUT I don't understand it being legal or ethical in anyone's reality to starve another human being to death if she can safely swallow food and fluids. A meal tray is not life sustaining medical treatment. To withhold food and water from someone who can safely eat is NOT passive euthanasia. It is homicide. A cruel manner of homicide at that.

Finally, I wanted to give you a virtual hug and some encouragement for being such a wonderful advocate for this lady. She needs one! Excellent work, Nurse. (((Hugs)))

This was my initial thought as well – an untreated UTI can go south fast, especially in an elderly patient. 79 yr old ladies tend not to eat or drink that much to begin with, and if her TFs have just been DC’d, it’s not likely that her nutritional status (and fluid balance if not taking enough PO liq) is up to the task yet, in these first few days beginning a real diet, to fend off potential urosepsis or ARF. Plus, UTI’s have a way of making elderly people loopy (ALOC/AMS), so now is also an unfortunate time to be trying to get a competence eval. She may not be at her cognitive baseline with an underlying infection going on. Not to mention the grief she is experiencing with her loss. Lost her husband + unable to clearly communicate/make wishes known + UTI + no meds + no TF + probable inadequate PO intake + uneducated family + MD that (IMO) appears to have given up too quickly = horrible, perfect storm.

I’m disappointed in the MD that came to you with tears in her eyes and told you to DC the TF and stated no abx for the UTI. This does not seem to be the patient that should have simple Rx withheld (it’s Macrobid, for cripes sake, not Levophed), and makes one wonder if she explained Advanced Directives/POA to the sons in a way that they understood what it actually means (see Esme’s very first post, pg. 1). At what point does deciding against such a simple treatment become “neglect” (in an otherwise non-terminal individual with a thus-far unmeasured cognitive deficit, and has not been deemed a hospice candidate)? I’m asking because I admittedly do not know. I see plenty of hospice patients admit to the hospital with UTIs and hip fx’s that are treated, and go right back on hospice service when they are discharged. If the MD is also concerned with the ethics of the healthcare decisions being made, is she planning on moving this forward? What do her Progress Notes state?

Specializes in Labor/Delivery, Pediatrics, Peds ER.

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.

Wow. Incredible. Kudos to you for what you are planning and for your concern. To me, it's unconscionable to let people suffer with UTI's and to not feed them. Most especially since it's obvious this poor lady is not even in any sort of coma. (In which case, I'm still a die hard when it comes to withdrawing treatment.)

Those kids showing up and saying she would never want to be half paralyzed and on a feeding tube? Well, she's been that way for over a year, sits up in a chair (with help) reads the paper, listens to music, etc. Doesn't sound in the least like someone who feels her life is not worthwhile.

I agree with the person who said these kids just want to get on with their lives with her money. I'm praying she will be able to respond to you in letting her wants be known in a way that no one can refute.

Waiting to hear the upshot!

Specializes in Labor/Delivery, Pediatrics, Peds ER.
Wow. I am almost without words. But I'll figure some out.

Years ago when I was a CNA in LTC, we had a resident who was not actively dying; he was taking 100% of his nutrition PO, and even had some impressive muscle tone for someone who was non-ambulatory. He *looked* healthy. His wife at one point refused antibiotics for a UTI because she didn't want to "prolong his life." My facility did have an ethics committee which convened on this issue. 1) he wasn't dying, 2) DNR =/= do not treat, 3) at best, letting someone be in pain from a UTI is cruel, and 4) allowing him to die of urosepsis would be unspeakably cruel.

I thought of this gentleman when reading your post. I would have issues even if someone WAS on hospice and dying, with not treating a UTI because UTIs are so painful. It feels like urinating shards of glass! Treating a UTI, in my humble opinion, would be a comfort measure.

Esme gave some great resources, which I encourage you to avail yourself of *forthwithal* (my word of choice when "immediately" or even "yesterday" just isn't strong enough.)

This woman is not dying. If nothing else she needs as complete a speech eval as she needs to be able to take PO, if she passed her swallow eval but hasn't been officially given the order to take PO. Withdrawal of tubefeedings is a debatable ethical issue (is it life-sustaining treatment, or is it food? Are you letting the disease take its natural course, or are you starving a person?)...BUT I don't understand it being legal or ethical in anyone's reality to starve another human being to death if she can safely swallow food and fluids. A meal tray is not life sustaining medical treatment. To withhold food and water from someone who can safely eat is NOT passive euthanasia. It is homicide. A cruel manner of homicide at that.

Finally, I wanted to give you a virtual hug and some encouragement for being such a wonderful advocate for this lady. She needs one! Excellent work, Nurse. (((Hugs)))

Amen to that!

I have heard many times in various places about decisions not to treat UTI's in patients deemed terminal, and I have always been aghast. As you said, they are incredibly painful, and not just necessarily when one tries to urinate. I do not understand why anyone would consider not treating a UTI. It's not like it's going to prolong someone's life. It's a comfort measure, as far as I see it, and not treating it hastens demise.

In addition, I feel the same about withdrawing feedings. I wonder where we have come that these things are even considered reasonable tactics. And tactics they are. They are certainly not benevolent care.

Specializes in Rehab, LTC, Peds, Hospice.

Definitely call the ombudsman. You'll be anonymous, if it's neglect a guardian can be appointed instead of the sons as durable power of attorney. Speech services can still go on through Hospice and with Hospice often we have the ok to feed po as per patient comfort and patient wishes, ie if my patient wants a hamburger, he gets a hamburger :-) Also refer to Social services and put it in the chart.

Also - re UTI - is she febrile? Our doctors won't treat unless they are actively symptomatic - having pain/discomfort, fever, urgency as they say antibiotics are over used and often results are due to colonization.There is a good chance she won't get septic even if not treated.

Best of luck and hugs, know these situations are just so hard and heartbreaking. I want you to know you that are truly being the best patient advocate you can be too. That's nothing small, and something to hold onto if this doesn't go the way you hope. Glad there are people/nurses like you in the world. Hugs again

I just wanted to say that I think you are a great nurse and this is a perfect example of being a patient advocate. I agree with everyone that this issue needs to be addressed further and look forward to reading your follow up. I'm hoping that her sons just misunderstood her prognosis. I don't agree with d/c feedings or antibiotics unless death is imminent.

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