Spouse vs. MPOA and feeding tubes

Nurses General Nursing

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Did you know that if a feeding tube is inserted (either temporary or permanent), your spouse/next-of-kin cannot by law ask that it be removed or that you stop being fed by it unless they are also your medical power of attorney?

The spouse can give orders to not do CPR, to take out breathing tubes, turn off vents, stop drips, etc. But is powerless to make decisions about feeding tubes. It seems nonsensical.

I had a case recently where a person's spouse determined that the person had had enough, there was no hope of getting better, and the person would never want to be sustained long-term in this condition. The spouse asked that the NG feeding tube be removed and tube-feedings stopped. The tube had only been in place for about 2 weeks after a medical event, and the patient had not yet left the ICU after that event. But the spouse was then told the law did not allow for that.

The patient would have to continue with the feeding tube until or unless:

a) the patient pulled it out themselves (this patient was not capable of that)

b) the patient's legally designated MPOA made that decision

c) a judge ordered it.

d) doctors determined that the tube-feeding caused further harm to the patient.

In the case of my patient, they were dying, and tube-feeding led to fluid overload, so orders were given to stop feeding. However we had to leave the tube in, unused, and the spouse had to have their last memories be of that ugly tube sticking out of their loved-ones nostril while they passed away.

This is an important reminder for all of us to formally designate a medical power of attorney, have it notarized, and file it away long with a statement of your wishes. Don't assume that your legal spouse can make all decisions for you without this paperwork.

Pet peeve of mine, nurses who quote things as laws or policies and don't actually know where said law or policy is in writing. It's a 50/50 shot whether it actually IS a policy/law or not. I almost always find the dang policy in writing then put on my clipboard so when I tell someone this and they look at me like I'm stupid or wrong I can make a copy or hand it to them. I'd venture to guess that this "law" you are citing varies from state to state and challenge you to find the actual law for your state as a reference. Some states do have very specific laws so I'm not challenging you that you are wrong. I suspect you are right, but I think it's worthwhile to know the actual laws on this in your state.

It actually IS the law in my state. We looked it up (doctor looked it up and consulted with some legal experts). I am not uninformed.

It actually IS the law in my state. We looked it up (doctor looked it up and consulted with some legal experts). I am not uninformed.

Which state, and which statute?

Specializes in Pedi.
It actually IS the law in my state. We looked it up (doctor looked it up and consulted with some legal experts). I am not uninformed.

So can you please cite the law so we may read it?

Specializes in Rodeo Nursing (Neuro).

I once had a family member ask that their dying loved-one's Dobhoff be withdrawn. At my facility, this has to be done by an MD. So I paged the resident, who gave me my first (of many) experience with, "Let's see what the primary team says in the morning." It was 0430 and made sense, to me, but my mentor gave me a look that let me know I maybe wasn't being an effective advocate. She had a point--as always--but since then I'm more sure than ever that the resident and I were right. A hose in your nose IS uncomfortable, but nowhere near as bad as it looks. Having survived heroic measures, I have myself a whole new set of heroes, and ZERO memory of the horror show I looked like. My NG came out when I could feed myself and take p.o. meds. After my first taste of hospital food, I was a little nostalgic for that NG. Except the tape. The tape on your nose sucks.

I once had a family member ask that their dying loved-one's Dobhoff be withdrawn. At my facility, this has to be done by an MD. So I paged the resident, who gave me my first (of many) experience with, "Let's see what the primary team says in the morning." It was 0430 and made sense, to me, but my mentor gave me a look that let me know I maybe wasn't being an effective advocate. She had a point--as always--but since then I'm more sure than ever that the resident and I were right. A hose in your nose IS uncomfortable, but nowhere near as bad as it looks. Having survived heroic measures, I have myself a whole new set of heroes, and ZERO memory of the horror show I looked like. My NG came out when I could feed myself and take p.o. meds. After my first taste of hospital food, I was a little nostalgic for that NG. Except the tape. The tape on your nose sucks.

Why were you sure that you and the resident were right? I'm not saying you weren't as I don't know the situation, but am just wondering why you thought this. It sounds as though the family member wanted to withdraw care, i.e. feeding, for the patient who was dying; this would be very different from your situation where you had an NG tube (I don't know the details of your situation, but you didn't indicate that you were dying). I'm not sure how your situation is comparable to the patient's except that you both had a tube in your nose.

Specializes in Rodeo Nursing (Neuro).

Obviously (in hindsight) I wasn't dying. Except, by all logic, I was. I'm here because my surrogate and some of the nurses who cared for me pushed the docs to go beyond what was reasonable (and because the docs did so as if they believed it would work.) My logic with that early patient was that leaving the Dobhoff in place was easier to reverse than taking it out would have been, and that looking unpleasant was not the patient's major issue, just then. If I remember correctly, feeding wasn't an issue by then, so yeah, we could have given meds and fluids IV. And I really don't want to minimize the family's difficulty seeing their loved one like that. One of my friends told me that when she visited me, she felt like an idiot for making me laugh while I was intubated. I don't remember that, either, but it sounds about like both of us. And my general point, especially after my own experience, is that death is permanent, while life is temporary. If I could redo my experience with that patient way back when, I would try hard to educate the family that the tube might look bad, but wouldn't cause the patient to suffer. And I'd actually know that was true. (Per the OP, I now know reversing the NG might not be as simple as I thought But physically, it's easy, so let's let the easy stuff ride until we've dealt with the hard stuff.)

ETA: I believe more than ever that death is a transition, not an end. But it does limit your options.

Obviously (in hindsight) I wasn't dying. Except, by all logic, I was. I'm here because my surrogate and some of the nurses who cared for me pushed the docs to go beyond what was reasonable (and because the docs did so as if they believed it would work.) My logic with that early patient was that leaving the Dobhoff in place was easier to reverse than taking it out would have been, and that looking unpleasant was not the patient's major issue, just then. If I remember correctly, feeding wasn't an issue by then, so yeah, we could have given meds and fluids IV. And I really don't want to minimize the family's difficulty seeing their loved one like that. One of my friends told me that when she visited me, she felt like an idiot for making me laugh while I was intubated. I don't remember that, either, but it sounds about like both of us. And my general point, especially after my own experience, is that death is permanent, while life is temporary. If I could redo my experience with that patient way back when, I would try hard to educate the family that the tube might look bad, but wouldn't cause the patient to suffer. And I'd actually know that was true. (Per the OP, I now know reversing the NG might not be as simple as I thought But physically, it's easy, so let's let the easy stuff ride until we've dealt with the hard stuff.)

ETA: I believe more than ever that death is a transition, not an end. But it does limit your options.

It sounds as though you went through a lot, but I'm afraid your post is not making sense to me. What's important is your patient's wishes in regard to their Dobhoff tube, i.e. did the patient want the tube to stay in them or be removed - what were the patient's end of life wishes in regard to treatment? It sounds as though they were dying and unable to say what they wanted, so their family member, as POA or next of kin, expressed the patient's wishes (as they understood them) for them, and said they wanted the tube removed.

Also, what one person finds tolerable (you, with the NG tube), another person may find intolerable; you can't assume that another patient's experience will be similar to yours. Our role as nurses includes being an advocate for the patient and their wishes, not projecting our experiences onto them.

Specializes in Rodeo Nursing (Neuro).

Susie2310, I've had to give your post some thought, mainly because there's nothing in it with which I disagree. And yet, I still feel I was right, or at least partly right. So I've really had to ponder "Why?" My experience of having an NG probably only clouds the discussion, except that it did seem to confirm what I believed at the time, that the discomfort of having one hardly rises to the level of suffering. And you're quite right--what's tolerable to me might not be to another. Still, we do have to use our judgement, and I'll stand by mine that having an NG isn't all that bad. Clearly, feeding can add to a patient's suffering, but if I recall correctly, we weren't feeding at that point. You are also correct that a patient or his agent can withdraw consent at any time, although it appears from what I've seen on this thread that feeding tubes may be an exception (so maybe I actually was right, albeit for the wrong reason.)

I thought at the time that leaving the tube in place would be a lot easier to undo than pulling it out, so I wanted everyone to be sure before it was pulled. A weakness in that thinking was that it almost certainly could be replaced, if a reason to do so arose. I also thought, and still do, that the family member was more concerned about how the patient looked than how he felt. That, arguably, was none of my business, but it's also crucial to my position. After some reflection, my conclusion is that as the patient's advocate, I had to consider whether the family member was sufficiently informed to make a decision in the patient's best interest, and I didn't--and don't--think she was. In the course of my practice, I have had to recognize a competent patient's right to exercise his own bad judgement. But that isn't to say I couldn't, or shouldn't, try to dissuade him from making a mistake. At least occasionally, if I explain to a patient why he should do this or shouldn't do that, he listens. By the same reasoning, I'm pretty sure it was okay to tell this patient's family member that the tube didn't hurt and that leaving it in place would give us options we wouldn't have without it. I'm less sure, but still fairly sure, that under the circumstances it was appropriate to delay a final decision until wiser heads could speak with the family member and ensure that she fully understood what she was saying. Again, it has been a long time, but I'm thinking I recall that a palliative care consult was already scheduled with an eye toward making him CMO, and I think that would have been the appropriate time to decide about the tube.

What your post makes me question is whether I was making myself a dilemma where none existed, but I think my answer boils down to, my ethical duty was to call upon all of my knowledge and judgement, rather than simply defaulting to a textbook answer. Indeed, I'm just now reaching the conclusion that the "art" of nursing occurs when we choose what we "know" to be true over protocols and algorithms a robo-nurse could implement. That's a statement to give lawyers and administrators ulcers, but if it does, they'll be better off for having human nurses caring for them during their treatment.

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