ethical dilemma

  1. I work in LTC. I have a senior citizen living in that LTC who is ordered NPO by his physician and receives GT feeding 24 hours a day. Everyday during meal times, he asks for food and becomes agitated because everybody else got a tray but him. He used to eat before he went to the hospital but ever since he came back from the hospital, he is NPO. He asks for food like a small baby, you should see the expression in his face- it breaks my heart. he says- I didn't eat for last one week, rescue me..give me something to eat please !!! I want a cup of water.
    I asked the speech therapist for swallowing evaluation and she recommended puree diet. But the doctor did't even want to listen and it was a big NO NO from him. He just told this- "who will be responsible if he aspirates? Will you? he aspirated when he was in the hospital.". I discussed this with the speech therapist again and the speech therapist said at this time he is tolerating puree diet. She further recommended video swallowing evaluation. The MD again refused to have this test. He claimed- he aspirates and there is no need of this test. He will fail the test.
    Even though we make every effort to isolate these NPO people during meal times, the smell and sight of food is not always avoidable. There are two things that aggravates the agitation in this gentleman- food and elimination. He wants to use bathroom and doesn't wet his diaper. Everytime he wants to go to the bathroom- he tries to get up and if he is not allowed he will be agitated. He will be shouting- let me go to the bathroom. It is understandable.
    Day before Yesterday, he was taken to some other floor during lunch time and he became very agitated and the therapeutic recreation chief asked me to have a psychiatrist see this man and "prescribe something to calm him down". I asked- what did he want? Food or he wanted to go to the bathroom? The guy said- he didn't know, but this gentleman was out out of control. As soon as he came to the floor, he was taken to the bathroom and was very calm and quite after that.
    Next day- the unit manager asked me not to feed anybody with too much of inofrmation otherwise I will be in trouble (because I told the recreation chief that food and elimination are the only two reasons for his agitation) and call the psychiatrist to increase the dosage of meds. He already is on a very high dosage of psychotropics and we know what triggers his behavior. How could we expect him to sleep 24 hours a day? Even now he sleeps most of the time. Is psychotropic a solution for this gentleman? Should I offer him food despite the physician's NPO order? how can I solve this problem?
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    About starbin

    Joined: May '05; Posts: 423; Likes: 72
    RN; from US
    Specialty: Nephro, ICU, LTC and counting

    23 Comments

  3. by   crissrn27
    Can the family get involved here? Sounds like a care plan meeting with nurses, doc, pt., and family is in order.
  4. by   EmerNurse
    Good grief!!! This poor man - if I wanted to eat or pee in a toilet, I'd be insanely upset to have someone say no. This doc needs to get the swallow eval done - WHAT is his problem? Is there family involved that you can go to?

    I don't know a lot about how LTC works and how docs are assigned, but is there another doc you can go to? Annonymous tip to an ombudsman?

    Even if the poor guy can't eat enough to fulfill nutritional requirements, even a few bites, given properly, of proper food, would give him back his "right" to eat. As for the toileting, is there someone who can take him to the bathroom or BSC? Can he ambulate at all?

    It may be my kneejerk reaction, but this situation would tear me up, too. Quality of life is important -this is this man's home, for heaven's sake. Maybe the guy would prefer one day to die with the taste of puree'd beef on his tongue, than live an extra few months without ever tasting food again.

    Please keep us updated, I'm interested in how this is finally resolved. Sorry I couldn't be more help. Oh, btw, do not feed this man behind the doc's back. IF something happens, it's your license, and while it's sad, YOUR life counts too.
  5. by   starbin
    [quote=crissrn27;2174531]Can the family get involved here? Sounds like a care plan meeting with nurses, doc, pt., and family is in order.[/quo
    Sadly, he has no family.
  6. by   abooker
    In my LTC facility, residents and/or resident families have fired their doctors. Is there another doctor that would be a better "fit" for this resident?

    Be careful with your unit manager - maybe somebody else could mention switching doctors as an option.
  7. by   starbin
    Quote from EmerNurse
    Good grief!!! This poor man - if I wanted to eat or pee in a toilet, I'd be insanely upset to have someone say no. This doc needs to get the swallow eval done - WHAT is his problem? Is there family involved that you can go to?

    I don't know a lot about how LTC works and how docs are assigned, but is there another doc you can go to? Annonymous tip to an ombudsman?

    Even if the poor guy can't eat enough to fulfill nutritional requirements, even a few bites, given properly, of proper food, would give him back his "right" to eat. As for the toileting, is there someone who can take him to the bathroom or BSC? Can he ambulate at all?

    It may be my kneejerk reaction, but this situation would tear me up, too. Quality of life is important -this is this man's home, for heaven's sake. Maybe the guy would prefer one day to die with the taste of puree'd beef on his tongue, than live an extra few months without ever tasting food again.

    Please keep us updated, I'm interested in how this is finally resolved. Sorry I couldn't be more help. Oh, btw, do not feed this man behind the doc's back. IF something happens, it's your license, and while it's sad, YOUR life counts too.
    That scares me. I can't feed him. This man walks (with unbalanced gait) but safety is again a concern. You can imagine, someone knocked out with drugs and woke up with an urge to pee, he wants to go right away and there may not be someone available all the time, so he has to wait.
    Contacting some other doctor for him is beyond my capability.
    Last edit by starbin on Apr 25, '07 : Reason: addition/clarification
  8. by   SuesquatchRN
    One of the things I dislike about LTC is my poor old folks just want a little salt on their pureed mush, one resident is on ground meat and stated that she'll sign something exonerating us from blame if she chokes on real food - we are all concerned about "quality of life" yet deny them the simplest pleasures. Yes, their lives might be shortened by a few weeks but are we really meant to subsist until we end up as vegetables?

    That poor old one. I hope you can get him some food and drink.
  9. by   debthern
    doesn't this patient have a case worker or someone that is his advocate? Something needs to be done for him that's for sure, the poor man, and that doctor needs a new attitude. This is one of the major reasons I don't do LTC.
  10. by   gonzo1
    This is heartbreaking. Don't feed him though, unless you can get permission to do so. Keep advocating for him. This is why I could never work in LTC. I would be having nightmares about what is done to these people. Thanks for your care and compassion to them.
  11. by   starbin
    [quote=debthern;2174584] and that doctor needs a new attitude. quote]
    I agree
  12. by   kmoonshine
    Also, make sure you are documenting everything. Make sure to write something like this:

    RN contacted speech therapist regarding pt's request to eat; speech therapist recommended pureed diet. Pt request for food and speech therapist diet recommendation reported to MD, no new orders recieved. RN contacted MD and advocated for a video-taped swallow study based on speech therapy recommendation; no new orders recieved. MD states "he aspirates and there is no need of this test. He will fail the test". Pt continues to become aggitated when told he cannot have food by mouth; pt reassured of treatment. RN contacted nurse manager regarding situation. Will continue to monitor.
  13. by   morte
    if the patient's doc is not the med director of the facilty, go to the director...if he is and/or the owner is it possible that there is a higher rate of recompense if the patient "requires" a gtube? you could try the ombudsman, or the entity that is paying the bill (medicare/medicaid)...good luck
  14. by   jill48
    You are his advocate. It's sad he has no family, which makes it even harder for you because it sounds like you are his only advocate (on this matter anyway). When I read this I found it very sad, but I was also very proud of you, my sister nurse, because you have such a big heart and want the very best for your patient. You were not feeding too much information to the therapist; the therapist is part of the team; it's not like you were telling him lab results. You cannot feed him, regardless of how bad you want to, until the physician changes the order. Is there not one single family member that can speak to the doctor? Because that is probably the only thing that will make him change the order. You said that the speech therapist performed a swallow test and ordered a pureed diet? Then why isn't the doctor allowing this? I would go to the medical director and beg (yes, I would beg for my patient) to take the swallow tests into account. You probably sit back and think to yourself, "why am I pushing so hard when it's just about him wanting to eat?" Well eating is not a little thing. It may be one of the last pleasures he has left in his life. Why should this be denied to him if he can swallow pureed food? Nursing school was a long time ago for me, but I seem to remember there was some triangular diagram about basic human needs, and I'm pretty sure eating was one of them. Please don't stop fighting for him. Just be sure to do it correctly, following all orders. Good luck, sweetie. Your doing very good. :icon_hug:

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