Spouse vs. MPOA and feeding tubes

[anon456, BSN, RN]

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.

[KatieMI, BSN, MSN, RN]

Yeah, and not only feeding tube. DPOA can turn your vent off as well, doesn't matter what your other dear and loving ones want to say about the subject. And sometimes it is something pretty much close to a blessing.

In LTACH where I worked, we pretty commonly had patients on chronic life support whose families were, to say the least, not quite adequate in their expectations. Sometimes the torturous "treatment" continued for decades while families expected some genius of medicine or, probably, the Lord himself to "finally fix' mom right up and made her like she was before" while pocketing mom's SSI checks in the meantime and often vehemently denying her pain meds and comfort measures "so that she would participate in therapy/see all of us here/know that we love her/etc." Once the business with that check became known (or things really went out of any semblance of control), the Powers brought the case to hospital's ethics commission which duly pronounced all further care medically futile. Family, of course, disagreed, and then the case was taken to Court which, using the fact that those families hardly ever took any care of "papers", appointed DPOA. Thus, patient became "the ward of the State", and the DPOA gathered the poor doctors second time for formal pronouncement of futile care. After that, patients were almost universally moved to comfort care/hospice. Believe me, for too many of them it was the first time in years when they were free of pain and unhuman suffering inflicted upon them by modern medical care and their "loving, hoping" families.

[JKL33]

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.

At that point why wouldn't it have been simply a noxious/painful thing to have in place that would be removed as part of the initiation of comfort measures?

Sorry, I don't deal with TFs a ton. Is there a particular rationale for this? It's okay if one stops breathing but not okay to remove an irritating device that is no longer being used?

[anon456, BSN, RN]

At that point why wouldn't it have been simply a noxious/painful thing to have in place that would be removed as part of the initiation of comfort measures?

Sorry, I don't deal with TFs a ton. Is there a particular rationale for this? It's okay if one stops breathing but not okay to remove an irritating device that is no longer being used?

The law is very clear that feeding tubes not be removed. Any other kind of tube, yes. And I suppose if the tube was causing tissue damage it would be removed-- and replaced in the other nare if possible.

[MunoRN, RN]

I think maybe you're misunderstanding the laws related to this as there are no laws that state what you are describing.

A spouse is often the default POA following the usual next of kin list, but if for some reason the spouse is not the POA then there isn't a differentiation vs a feeding tube vs other life sustaining treatments. Although in general, the POA isn't really the 'decision maker', their role is to convey the decisions that the patient would have made, so even if the spouse is not the decision maker, if there is reason to believe the spouse has a better understanding of what the patient would want in certain circumstances then it would be their input that would guide those decisions.

[LovingLife123]

They were using a NG for tube feedings for two weeks?

[morte, LPN, LVN]

I think maybe you're misunderstanding the laws related to this as there are no laws that state what you are describing.

A spouse is often the default POA following the usual next of kin list, but if for some reason the spouse is not the POA then there isn't a differentiation vs a feeding tube vs other life sustaining treatments. Although in general, the POA isn't really the 'decision maker', their role is to convey the decisions that the patient would have made, so even if the spouse is not the decision maker, if there is reason to believe the spouse has a better understanding of what the patient would want in certain circumstances then it would be their input that would guide those decisions.

I would think it varies by state.

[anon456, BSN, RN]

I think maybe you're misunderstanding the laws related to this as there are no laws that state what you are describing.

A spouse is often the default POA following the usual next of kin list, but if for some reason the spouse is not the POA then there isn't a differentiation vs a feeding tube vs other life sustaining treatments. Although in general, the POA isn't really the 'decision maker', their role is to convey the decisions that the patient would have made, so even if the spouse is not the decision maker, if there is reason to believe the spouse has a better understanding of what the patient would want in certain circumstances then it would be their input that would guide those decisions.

MPOA vs. Next of Kin:

The MPOA is a legal designation. The patient fills out a form that is notarized, on which they state who they wish to be their MPOA. That person's word then supersedes the authority of any next of kin.

I have seen patients who have their best friend as their MPOA because their spouse may not respect their final wishes.

There is very often not a legal, designated MPOA. In which case the decisions go to the next of kin. There is then a "rank" of which next of kin have rights in which order-- again this is law where I live. Spouse, then children, then other relatives, etc. down to friend, neighbor. Surprisingly in my state (or maybe not-- we are pretty backwards here .. ) "partner" is down pretty far on the list if the couple is not legally married.

No MPOA, and there is a feeding tube, the next of kin cannot make that decision, specifically involving feeding tubes. Only those listed above can in the OP.

The moral of this story is to get yourself an MPOA signed on a paper, and a living will. We all should.

[anon456, BSN, RN]

They were using a NG for tube feedings for two weeks?

Yes. . is this surprising to you? It is not uncommon to do this while waiting to see if the patient will need one long-term or not. Or if the patient is not stable enough to do surgery on. In the pediatric world babies and children can have them for months.

[MunoRN, RN]

MPOA vs. Next of Kin:

The MPOA is a legal designation. The patient fills out a form that is notarized, on which they state who they wish to be their MPOA. That person's word then supersedes the authority of any next of kin.

I have seen patients who have their best friend as their MPOA because their spouse may not respect their final wishes.

There is very often not a legal, designated MPOA. In which case the decisions go to the next of kin. There is then a "rank" of which next of kin have rights in which order-- again this is law where I live. Spouse, then children, then other relatives, etc. down to friend, neighbor. Surprisingly in my state (or maybe not-- we are pretty backwards here .. ) "partner" is down pretty far on the list if the couple is not legally married.

No MPOA, and there is a feeding tube, the next of kin cannot make that decision, specifically involving feeding tubes. Only those listed above can in the OP.

The moral of this story is to get yourself an MPOA signed on a paper, and a living will. We all should.

A person can designated someone specifically to be their POA, which then overrides the hierarchy of next of kin that would become the POA by default.

However there are no laws that say that the person who can withdraw life sustaining treatment cannot also have a feeding tube removed.

[LovingLife123]

Yes. . is this surprising to you? It is not uncommon to do this while waiting to see if the patient will need one long-term or not. Or if the patient is not stable enough to do surgery on. In the pediatric world babies and children can have them for months.

Yes, it's very surprising to me. NGs are only used as a last resort to feed where I am. But the use of those and SBFTs is limited and not used long term due to the risk of infection to the sinuses. We very rarely use an NG to feed. NGs are used mainly for decompression where I am.

[Julius Seizure]

I dunno. They might find that my dying family member accidentally pulled out their feeding tube when nobody was in the room with us. Whoops.