ethical problem... need opinions

[txspadequeenRN]

I have a situation at my job that I do not feel comfortable with and I would like to get some opinions. I have a patient and he has a G tube and we were giving him feeding 5 times a day. He gets up in the W/C daily and rolls himself around, seldom starts conversations but will talk to you when you speak to him. About 10 months ago he went unresponsive and when I spoke to his family about either sending him out or getting labs at the facility and seeing what happens their response was "Oh what ever he needs lets do it". Then he started coming around and everything from there was ok . He was back to being himself. His family seemed so caring and concerned. Now Im going to fast forward to present time and 3 weeks ago I come to work and his feedings have been cut to 2 times daily and they are giving him pleasure feedings. Now this to a geriatric nurse seems like a progress in the right direction except.... His family requested he be put on hospice and allowed to die naturally. He has had NO change , no decline. They have made the commit to the staff.."We want him to choke and die". They say he has no quality of life and death is the best thing for him. I am very uncomfortable with this situation and find it unethical. This man still gets up and can hold a short uncomplicated conversation with someone. Their reasoning also could be financial but I feel bad for this man. They never come to see him but have always been gung ho for "getting whatever he needs". I just want some other insight here. I feel for this patient but also wonder where I stand in the ethical/ legal part of this.

[bawms]

I would talk with my DON and Social Services. Being it is private pay facility, money can be the issue with the family, you would be surprised how greedy people can be. There are ways his POA could be changed/ court ordered and if he is in his right mind he can make his decisions known, document , document, document and don't give up. We are the patient's advocate.

[leslie :-D]

even a psyche eval, to determine competency, might be helpful now.

i know he has a poa, but since there has been such a drastic change in his plan of care, it might benefit him (or even the facility) to have updated records, reflecting his mental status and cognition.

i too, was thinking the ombudsman should be notified, just so an outsider is aware of this situation.

leslie

[subee, MSN, CRNA]

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!!!!

Achot chavi: You may want someone to force feed if you have Alzheimer's, but I can assure you that most people feel differently. Suffering is a feeding tube prolonging your death. Part of nursing is helping families and patients make these decisions without forcing your values onto them. IV fluids will keep the patient neither comfortable, nor alive. Everyone in the hospital dies with an IV and most of them aren't very "comfortable." If I am admitted, with my wishes clearly delineated, please do not interfere with my human dignity by overriding my choices. Thanks.

[achot chavi]

Achot chavi: You may want someone to force feed if you have Alzheimer's, but I can assure you that most people feel differently. Suffering is a feeding tube prolonging your death. Part of nursing is helping families and patients make these decisions without forcing your values onto them. IV fluids will keep the patient neither comfortable, nor alive. Everyone in the hospital dies with an IV and most of them aren't very "comfortable." If I am admitted, with my wishes clearly delineated, please do not interfere with my human dignity by overriding my choices. Thanks.

I would NEVER FORCE FEED or FORCE MEDS or FORCE anything on someone else (not even my husband!!!). I am not sure where you saw that in my posting, I wrote:"We had no choice but to try feeding..."

I am sorry if you thought that I advocate forcing- because I don't- not for ethical, emotional, or religious reasons!!!In the situation that I described we ALWAYS respected the families decisions and I do advocate educating families of all the options. They regretted their choice when it was too late to change it and that was my point. They hadn't realized how painful it would be to see their father/grandfather suffer from starving to death. Especially since he didn't choose to starve to death- he had Alzheimers!!

I agree that an N-G rube is painful- I had one for a few hours when I vomited blood during a pregnancy (turned out to be just esophageal irritation) and it was extremely uncomfortable.

I do respectfully disagree with your statement that "Suffering is a feeding tube prolonging your death" As I see it, we have many patients who continue to enjoy a level of "quality of life" with a G-tube (I agree that an N_G tube is too uncomfortable to allow for any quality of life although I understand those who do choose them for temporary solutions to malnutrition). I have also had patients grow stronger and healthier with the help of a G or NG tube and return to oral feeding or even indepency with meals!!!!

Regarding your statement about IV fluids- I meant that the fluid kept dehydration at bay and allow the patient to be more comfortable.

I hope never to see you at the receiving end of the Nursing Profession - I wish you a long and healthy life- but be assured I endorse respecting families and patients wishes even when they conflict with my own judgement and I would rue the day that nurses or doctors act differently. If you read my posting you would see that we always respected the families wishes even if we knew that it would slowly kill him with malnutrition. We were always gentle and caring- till the very end- My conscious is clear!

I'm glad we all agree that it is important to respect pt directives and preferences and never force feed or force meds or force treatment. We must always educate the pt and families of ALL the available Options.

Peace be with you,

[carolbear]

If you feel in your professional opinion that a decision about a patient's life has been made by the POA, was made strictly for the benefit of the family/POA, you should report this to the proper authorities, ie; the state you work in, the Ombudsman and try to involve Social Work. Like most people are encouraging, it would be worthwhile to ask him what he wants. Let him know the risks and benefits of what are being done in simple terms and see what he indicates. But if for any reason he is able to communicate that he wants to live, it is your responsibility to advocate for him. If he indicates he agrees with the plan of care, then you need to respect those wishes and be the very best support you can be.

I wish you the best and its always good to see nurses advocating for their patients.

[skemergirl]

I am a RN Case manager for a Hospice Agency and I can tell you it is not just up to the family to put someone on Hospice. First there must be a Dr's order to "evaluate and admit to Hospice if appropriate". Then A RN must go to the facility and "evaluate" the patient and the patient must meet certain medicare gudielines to be appropriate for Hosipce. If the patient does indeed deem appropriate for Hospice, this does NOT hasten death. Hospice is a program where the patient does not receive "curative treatments" anymore. This does not mean we stop feeding patients and nor do we deny them of pleasure foods. It is the patients choice and if he is incapable of making his needs known, then it is ithe family to choose. I believe it is cruel to keep pleasure foods from someone when they understand the risks. I have worked in a Children's Hospital in the ICU and in many other related fields of nursing and always have the best interest of the patient at heart. Keep us informed of the outcome.

[RNOkie]

You might want to check into the hospice policy. As a former hospice nurse, I know that there are many expenses the company will pay for if they are related to the "hospice" dx. That may be where the 2 feedings/day is coming from. I don't wish to offend any nurses that work hospice, as I feel it is a wonderful concept. However, like everything else, it eventually turns into $$$ and "numbers", and I have a real problem with terminal patients being "marketed". Kinda makes you feel like a vulture. Or it did me anyway. At any rate, it sounds like the ombudsman might be your best course of action. The more non-medical personnel that are aware of this, the better. What did the doc say regarding the order to decrease feeding? What prompted him to write it? If the pt is lucid, talk to him with a witness. There's your answer. Protect him when the family is around. Good Luck....

[fisherstoud]

I would contact your local area agency on aging. They have the authority to review the situation and take over poa from the family if they feel the patient is in jeopardy.

[maia139]

Whilst I can see how a death 'alone' could be viewed as a bad death, i cant help agreeing with capecod - that the patient made his own decision that he wanted proper food -quality of life can only be defined by the individual in question. As long as decisions are informed, im much more comfortable enabling a patient to do or die as they please, rather than doing what myself or a team feels is best for them. I feel there is not enough of this practised, at least in the UK... what about in the US? Do patients really get what they want, and not what is deemed acceptable medically?

[gbrentrn]

A POA only takes over making decisions WHEN YOU CAN NO LONGER MAKE DECISIONS FOR YOURSELF! Is this the case? If he can say anything that resembles his will to live, we MUST comply! Just remember....POA IS WHEN YOU CAN NO LONGER SPEAK FOR YOURSELF!

[txspadequeenRN, BSN, RN]

Thank you for all your replies. I have been let go from my job after 5 years for no reason and my point here is I will not be able to update ya'll on this case. I look everyday for a obit for this man and hope someone had the sense to listen to me and get some help for this man.

[manda1027]

I am so sorry that you have been let go from your job, but, maybe you can take this as a blessing and find somewhere that you can work that they treat the residents with more respect and dignity. Also you can let go of some of the stress of this situation, while you are in a "delicate" situation yourself. Congrats on the baby. Hope everything turns out well in the end. Hugs.:icon_hug: