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GT feeding stopped after family's wishes

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zmaldon zmaldon (New) New

I am in an ethical and moral dilemma. A patient has her feeding tube stopped as per family's wishes. The patient is still alert and can comprehend even though she is bed bound. I was convinced that it was her wishes as well but no living will was provided in her chart. Now they are medicating her with Ativan. Am I entitled to refuse to give her meds even though it's all set and done? The patient is not ill and I feel is being starved. What to do, I want to quit.

VANurse2010

Has 6 years experience.

You should contact your ombudsman (every nursing home has one) or see if your company has an ethics referral line. However, you cannot just refuse to give meds without discussing/getting an order from the physician. Additionally, you always have the option of discussing your concerns with the MD, because the ultimate responsibility lies more with him than you.

This is such a tough situation. However, remember, as nurses we have no idea what the patient may or may not have discussed regarding end of life care with their families. For all intent and purposes, she could have said STOP with the feeding tube already!! She could have said "this feed is making me ill, yuck, stop, I am done".

If the patient is alert, is there a communication that has been used? Can you ask her what her thoughts are? Does the patient indicated she is hungry or thirsty? Is there a reason that the patient can't eat or drink PO? Is that something that can be explored with a swallow evaluation?

I would call the omsbudsman, get your care team involved, social work and perhaps hospice.

Ativan would be my drug of choice if I were bed bound. Perhaps when you are not there is when this patient feels anxious, therefore, they are medicating appropriately--and keeping it going as to not make this patient stress more.

The choices that a patient makes with their family and doctor may not be what we would do, may not be what we would like, may not be what we think is prudent. But it is the patient's choice to make. And when it is not feasible for the patient to make the choice, then whomever they have chosen for their decision maker is set to task of deciding for the patient. (Hence why we all need to make that decision maker someone who would follow OUR wishes as opposed to anyone elses).

You can not refuse to medicate the patient on a thought process of your own personal beliefs. You can however, ask for a care team meeting to discuss the plan of care.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

If she's alert and can comprehend is there some reason why she no longer has the ability to make her own decisions? If you have some way of knowing she can comprehend (she nods or otherwise participates in communication) then it should often be possible to assess her wishes.

It's certainly not unusual to withdraw tube feedings. When a decision is made to allow a medical condition to run it's course, that may very well include stopping artificial nutrition which we sometimes incorrectly see as "starving" the patient. If a stroke (for instance) made a patient unable to eat, then it's the stroke that preventing them from getting nutrition, not us.

CrunchRN, ADN, RN

Specializes in Clinical Research, Outpt Women's Health. Has 25 years experience.

It is really hard to reespond to this without knowing if she is competent and was she included in the decision?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Take a look at another thread on this very subject...https://allnurses.com/general-nursing-discussion/advice-please-withdrawal-933344-page5.html#post7999656

I was told this was her decision

Take a look at another thread on this very subject...https://allnurses.com/general-nursing-discussion/advice-please-withdrawal-933344-page5.html#post7999656

I too recommend that the OP read this thread.

CrunchRN, ADN, RN

Specializes in Clinical Research, Outpt Women's Health. Has 25 years experience.

Then what is the issue? If it is her decision.

There's a very famous case in the law and medicine arena. Mrs. Candura in NJ was an elderly diabetic with a gangrenous leg. She refused surgery. She completely understood that if she didn't have it off she would die from it, and said she was ready to die. Her physicians agreed not to amputate because that was her wish. After a time she began to fail (die), and was not longer alert and oriented. At that time her daughter went to court to compel her mother's physician to amputate the leg to save her mother's life. The court refused to so order, saying, in effect, it would be unconscionable to know what her wishes were and then wait until she could no longer defend herself against unwanted medical intervention, in this case, amputation.

People do have the right to be left alone.

I think your discomfort with this is perhaps you aren't comfortable with death. For many young or inexperienced nurses, they have little or no personal experience with death; their parents may still be young, and maybe even their grandparents. If siblings or peers have died it's more likely to have been what's usually called "untimely." They get very upset when someone refuses this kind of care and it will result in death, especially if they think the patient is "not competent." This is a very important point: a hospital, nurse, or physician cannot declare incompetence. (repeat as necessary). I realize that this may not be an identified issue in your patient's case, but I mention it just in case for when she begins to fail and you begin to get even more uncomfortable.

"Incompetence" is a defined legal term. In the absence of a valid advance directive from an adult patient, if a relative wants to be declared the guardian for the purpose of directing care, this requires a hearing before a judge.

OK. Your lady is old. She has seen her grandparents die, her parents, perhaps spouse, siblings, certainly friends. She knows what this is all about and she is not afraid of it; she knows there really are worse things than death. She is ready. If this is her decision, your duty is to support her in it, your challenge is to do with kindly and with grace, and your opportunity is to learn something very valuable about it. Death is not necessarily to be feared. She is lucky she has the choice and her family and physician support it. Now she can be lucky her nurse supports it too.

This just happened with an older distant family member. She was able to make her wishes known. She was unable to swallow and had been using an NG tube. She said she disliked the NG tube, it felt very uncomfortable and she didn't want it anymore. The doc suggested that she consider either a g-tube or doing nothing and letting nature take its course. After multiple conversations with this family member and her immediate family, she made it clear she was done, and did not want a gtube, and was ready to let nature take its course. Hospice was brought in and she was made comfortable with medications, and she passed away about a week later. Everyone in the family is sad about her passing but very happy that she was able to make her own mind up about what she wanted. It sounds very similar to the case you are referring to. If the patient is able to express their needs, let them make their own decisions.

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

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Why would you want to withhold those meds? This is HER choice. She will die of dehydration (days to weeks) LONG before she would "starve to death" (weeks to a month or more) and the use of meds like Ativan and morphine are indicated to keep her comfortable. Give her good mouth care,re-position her as needed. If you can, call in hospice. Get a cd player at the bedside and play her fav music, bring in flowers and place them where she can see them.Get some lavender oil for the area.Spend some time with her, give her a hand massage.

People who go on hunger strokes in protest or for religious purposes all report a feeling of euphoria. I have seen this a number of times and I don't believe it's painful.

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

I think my mother would have used her last bit of strength to kill me if I had tried to force her to eat (or do anything) after she decided she had done enough and it was time to go. She slept peacefully away on meds with my step-father sitting beside her reading the paper. I am very grateful she had such a peaceful death in such a kind, caring environment that didn't try to force her live one more day of struggle.

She didn't have a tube of any kind (except nasal cannula) -- and didn't want one. She had gradually reduced her intake and no one tried to force her to take in anything she didn't want. It was all about letting her take the lead and allowing her to die in her own way and her own time.