ethical problem... need opinions

Meerkat · Jul 25, 2006

Hi Tx,

I wonder, if this man can hold a convo for a few minutes, can you ask him what HE wants? Or has he been deemed incompetant?

manda1027 · Jul 25, 2006

Have you spoke with any other nurses in the facility about this, I mean, like your DON or Administrator? Maybe they know something that you don't. Maybe his family thinks he is a burden to them financially, if that is the case, have you talked to his case manager? Have they tried to get him onto state assistance? If they do come to visit, I think I would watch closely, so that they don't smother him! If he has not been deemed incompetent, then he can make some of his own decisions. Have you spoken to his primary doctor about your concerns for him?

txspadequeenRN, BSN, RN · Jul 25, 2006

He has a POA that makes his decisions for him and the family went to a care conference with our admin staff and even though they dont agree there is nothing they can do about it (or so they say). If he went onto state assistance he would need to move from our facility because we are private pay . Everyone knows the situation and they just kinda turn the eyes to the floor when the subject comes up. I think they are in the same mind frame I am but just dont have the guts to say anything. I just dont know what to think anymore. Its like the families have the power to kill off their loved one if they feel they haved lived long enough or run out of money.

Have you spoke with any other nurses in the facility about this, I mean, like your DON or Administrator? Maybe they know something that you don't. Maybe his family thinks he is a burden to them financially, if that is the case, have you talked to his case manager? Have they tried to get him onto state assistance? If they do come to visit, I think I would watch closely, so that they don't smother him! If he has not been deemed incompetent, then he can make some of his own decisions. Have you spoken to his primary doctor about your concerns for him?

manda1027 · Jul 25, 2006

I feel for you, I have been in a similar situation before, I just held my ground and made my opinions known about the issue, but it doesn't sound like there is much left that you can do in this situation. Wish I could be more help. :heartbeat

CapeCodMermaid, RN · Jul 25, 2006

This is terribly sad. Has he been put on Hospice? What do they say? What does the doctor say? Private pay or not you can always call the ombudsman in. I'm all for self determination and my wishes are already written down if the time comes when I can't speak for myself, but this seems to be the man's family taking over where they really have no business. Please let us know how this turns out.

yadda_yadda_yadda, LPN, LVN · Jul 25, 2006

I've had 1 very similar situation: the patient/resident had been on a pureed diet for years...due to several strokes and cerebral palsy. He required nectar-thick liquids, had bedside suction...the whole 9 yards.

This particular resident complained a lot about the pureed texture & being self-conscious about not eating 'regular food'. Well, after a month or so of complaining to the doctor, he was placed on a REGULAR DIET! There was no 'advance as tolerated'. He went from pureed to regular in one days time.

The nurses nearly FELL OVER. The doctor's rationale was 'quality of life' and dignity issues for the resident. This resident didn't have any living blood relatives, -- his medical POA that was a long-time friend of the family. They supported the doctor, saying, "If he wants solid food, just give it to him!"

Of course, the dining room was supervised, so he always had watchful eyes nearby during meals.--- However...once his diet was changed, within a week, he was busy sneaking snacks every chance he could. He got some potato chips from another resident & was eating them in his room...He aspirated and was hospitalized with pneumonia---and was dead within a week of being admitted.----The doctor made the comment "at least he died happy"

Helloooo! He aspirated on a POTATO CHIP & died ALONE in the hospital! Not even around familiar caregivers and faces.

The comment from the family is horrible..no two ways about it.

If I were you, I'd document "how well meals are being tolerated"...Document the presence of supervision. Document patient teaching (chin tuck while swallowing, small bites encouraged, etc.)-- If care plans are done on this patient/resident, I'd mention it in the monthly summary, too...and indicate that ongoing monitoring is being done to assess/assure patient tolerance/safety.Your heart is definitely in the right place.

:twocents:

CapeCodMermaid, RN · Jul 25, 2006

OKAY..but if he was his own person then he had the right to decide what he wanted. I had a patient once...was almost 100 and he told me he was tired of eating "sqashed baby food". I explained to him that he could choke and get pneumonia and die on regular food. He said he'd been making his own decisions and would rather choke and die eating 'real' food than live on baby food/puree. He knew the risks and made the choice. What better way can we help some people who have really nothing left in their lives but the right to make a CHOICE? I hope if I'm in the home someone gives me the choice (...just ask my kids...they KNOW I'll come back and haunt them if my wishes aren't carried out!!)

PS. He gave up taking his meds too and lived a few years longer

Nurse_Pauline · Jul 26, 2006

This is an awfully complicated issue, isnt it? Which is why my own wishes are very well known. If this man can carry on a conversation, is he competent enough to make his wishes known? Has anyone actually asked the resident how he feels about it? His wishes? I firmly believe in QUALITYvs QUANTITY and would much rather enjoy my last days on earth doing something i WANTED to do, then something i SHOULD do. If he hasnt had a hospice consult,he probably should. They could also help with the legal/ethical issues. I would question, however, the total change of heart the family seems to of had. I try to be as pro-active with these things as i possible can, just to avoid these types of situations, but that isnt always feasable. Good luck and keep us posted. I'll be interested to hear how this works out.

PANurseRN1 · Jul 26, 2006

First of all, you can't simply "put someone on hospice." The pt. has to have a qualifying illness w/ a life expectancy of

If he does qualify for hospice, what of it? Hospice is not about euthanizing people; it's about making pts. with end-stage diseases comfortable.

CaseManager1947 · Jul 26, 2006

This case touches upon several issues with respect to self-determination and right to choose. 1) Just because someone has a DPOA for Health Care, does not mean or require that person to make decisions regarding health matters, UNLESS 2)the person in question (the principal) lacks capacity to make his own decisions. Incompetency is a matter decided by the courts, only. 3)If this person desires to decline further treatment and feedings, it should be so specified in some sort of living will document, which (at least under Kansas law) supercedes any other documents, If this individual has been diagnosed with a swallowing problem or dysphagia, requiring nutrition other than oral means, verified by testing such as Modified Barium Study, and the patient wishes to cease such treatment, 4)it is within his right, 5)as long as he comprehends the consequences of his refusal. Hospice is a good recommendation to at least determine if the patient is hospice appropriate, and if so they often can be of great support to clients and families both. Another option is if your facility has an ethics committee -this is an avenue for staff to approach w/o feeling like they're interfering in a non-clinical way. Many facilities have such committees for just such occasions as this. When it comes right down to it, its his life, and if he doesn't wish to be fed by tube anymore, then Hospice with lots of support is the best choice, but check to see about ethics consult availability.

Morghan, MSN, ARNP

ks.

achot chavi · Jul 26, 2006

What a pickle, I really feel for you and thank g-d there are pt advocates like you out there. I've been in similar situations but they've never turned out the way I'd have liked. We had one Alzheimers Patient who stopped eating (He forgot how to swallow and any foood put in his mouth just dribbled out). The family (and POA) refused a N-G tube or a G tube. We had no choice but to try feeding him and get in fluids through an IV\or subcutaneous drip). He died a couple of months later on the eve of his grandsons wedding. 2 days before he died the frantic family realizing what they did- asked if a n-g or g tube could be put in but it was too late. He trully suffered and it broke all of our hearts. We got Zero support from ADM. The SW tried to be helpful but claimed her hands were tied.

If there is any way to educate this family I guess you have to try or ask the SW to get involved. Try to do it with the support of your supervisor.

Bottom Line is...See the Serenity Prayer!!!!