Assignment: Feeding tube w/dementia patient

[olaureno]

I'm working on a group project and I think we're stuck. The hypothetical patient has advanced dementia such that she cannot recognize family members and has been hospitalized numerous times. She has no advanced directive and is incapable of making medical decisions. She is in skilled nursing following a hospitalization for aspiration pneumonia. She had a j-tube placed, approved by her husband (and caregiver) who was under the impression that it was a temporary measure and not meant to be life-long. She is becoming increasingly combative- part of which is due to her desire to eat and being NPO. Her quality of life has become quite poor and she is unable to perform ADL's independently. The distraught husband has expressed interest in assisted suicide. In Oregon we do have Death with Dignity, however she is not elligible due to her advanced dementia. My own research has indicated that artificial nutrition and hydration for patients with advanced dementia causes more harm than good.(https://sites.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/ANOREXIA%20AND%20WEIGHT%20LOSS/Pegs%20dementia%20editorial.pdf)

It is my understanding that the nurse cannot stop tube feeding without the patient requesting it- something that cannot happen. I feel that continuing tube feeding is causing harm to the patient, but who can make the decision to stop feeding? What does the law say? I have been at this for hours and I have no idea how to proceed. Any hospice nurses out there to save me??

[verene, MSN]

This is a complicated situation. Try looking into your local laws for decision making (e.g. who does the capacity for medical decisions pass to when the patient is no longer able and there is no advance directive, my guess here is her husband.). Also realize that in many tough ethical areas there isn't clear law that applies (part of what is so difficult in these cases) so also look at facility policies for calling an interdisciplinary care conference and/or ethics consult for this particular patient's situation. If you can't find specific polices as this is a case study, look for some readings on medical ethics, specifically medical ethics and legal issues of feeding and hydration.These should help get you started down a constructive path.

[Anonymous865]

Every state has a law that designates who can make medical decisions for someone who is unable to make decisions for themselves. Who this person is varies from state to state.

Google oregon health care representative if none specified

Usually it is something like the following persons in this order healthcare power of attorney, spouse, adult child, parent, etc

Interestingly in my state the law states clearly that a physician caring for the individual may not be the decision maker. In other states, the patient's physician is allowed to be the medial decision maker. That points to the importance of knowing what your state law is.

The law usually spells out how the decision maker should make the decisions. Should they make the decision based on what they know of the patient's values or should they make the decision they think is best.

Also look at Oregon law 127.580 Presumption of Consent to Artificially Administered Nutrition and Hydration

[HouTx, BSN, MSN, EdD]

I actually haven't a clue what your instructors would be looking for.... but in real life, this would trigger an Ethics consult. Nurses are not the experts, Ethicists are. We need to refer to them rather than take on this type of responsibility. All accredited inpatient facilities need to have Ethics resources for patient care situations.

[Kuriin, BSN, RN]

We get a lot of confused patients on our stroke unit, and in a lot of cases, just end of life patients. This also includes advanced dementia. It becomes a point that it is ultimately up to the DPOA what the decision would be as advanced dementia would be considered grave disability, IMHO.

[MunoRN, RN]

Being the patient's next-of-kin POA, the husband can choose to withdraw treatments including artificial feeding on behalf of the patient. Declining medical treatments that artificially prolong life are not unusual in cases of advanced dementia, as it's not a particularly pleasant condition.

[amoLucia]

Taking this artificial feeding situation another complicating further step would be to consider what to do if the tube were to become hopelessly clogged or to have slipped out (pulled out). I think of the LTC NOC nurses faced with unflushable tubes or ones whose inside balloon fails to deflate (GT). The tube (GT) is usually replaced in house or earns a trip to the ER. Hopefully a decision has been made for this dilemma beforehand and clearly COMMUNICATED to all.

Cessation of artificial feeding has gone so far as to the Supreme Court (remembering Karen Ann Quinlan).

I think in these types of complicated cases, a court-appointed custodian/guardian can be assigned to make determinations for the pt in compliance with current laws and in the pt's best interests.

[Kuriin, BSN, RN]

If a patient is going home with a NGT that is not bridled or to not have a GTube, then something is really wrong with that hospital.

[amoLucia]

If a patient is going home with a NGT that is not bridled or to not have a GTube, then something is really wrong with that hospital.

I'm confused. I thought we were talking something more permanently inserted, like GT and/or JT.

NGT are not typical for long term use in a SNF, like for OPs pt.

PS - what is "bridled"? Never heard that term.

[AliNajaCat]

Several thoughts, having seen this more than once:

Just because somebody put the tube in doesn't mean that it has to stay in. If the husband wants it out, it can come out, especially if the husband agrees. Agree that there should certainly be consensus on what to do when it gets clogged or she reaches it and pulls it out herself.

Just because she aspirates doesn't mean she can't go home with hospice tomorrow and have whatever the heck po she wants, or whatever her husband wants to give her. When she gets her aspiration pneumonia sooner or later, she can be a no-admit and have hospice comfort care until she passes naturally. She can get buccal/sublingual MSO4 for the air hunger. This works very well and decreases suffering (which is one of our prime goals -- we cant always cure, but we can relieve suffering).

[KelRN215, BSN, RN]

The husband can request to end artificial nutrition. That's what the Terri Schiavo case was all about. OP, you say the husband is the one who consented to the J-tube being placed. He can consent to it being removed or to its use being ceased.

[Kuriin, BSN, RN]

@amolucia,

Bridled means that the patient will go into interventional radiology to have the NGT wrapped around into the septum. It's less likely for the tube to get dislodged/removed; but, if the patient pulls hard enough, they will be bleeding a lot. ;o

AMT Bridle Family | Nasal Tube Retaining System & Pediatric