Committee says feeding tube not appropriate
The situation: A 36-year-old severely retarded male was hospitalized after becoming unresponsive to nutrition by mouth over a 24-hour period in a skilled nursing facility where he was a resident. The patient had been institutionalized since age 2 and suffered from a host of comorbid conditions, including seizure disorder and congenital blindness. He also was microcephalic, says a risk manager who co-chairs the ethics committee.
"Prior to the hospitalization, the patient had been a resident in the skilled nursing facility for three months and was transferred from another facility because it was being closed. There was no medical history prior to this facility or any record of the patient’s family being involved in his care. The patient did have a public guardian but never had visitors at the nursing facility or while he was hospitalized," the nurse tells Medical Ethics Advisor.
Based on available medical history, the patient had never walked, talked, or communicated with his caregivers other than occasionally making grunting noises. Additionally, he would respond to music by moving his head back and forth and occasionally suck his thumb and move his right hand up to his face. Otherwise, he usually remained in a fetal position, she says. "The patient weighed 76 pounds upon admission and was refusing to be fed by mouth. We were concerned that he wasn’t eating because his body had become toxic from the anti-seizure medication dilantin. We started an IV, ordered some blood tests, and he became somewhat responsive," she recalls. The patient’s care team thought that if he started showing improvement he would be able to regain normal nutritional feeding through the mouth. "But the attending physician then brought up the questions What if he doesn’t get better? and Do we want to put a feeding tube in if there’s no reason to believe his condition will improve?’"
The consultation and discussion: Ethics consultations are conducted by the co-chairs and then jointly taken to the entire committee if a review assessment determines it should review the case. The case was deemed necessary for committee review, so each member observed the patient over the next 24-hour period.
"We have policies and guidelines in place concerning the types of patients who should and should not be placed on artificial feeding tubes, but in this case there was no way to determine what the patient’s wishes were regarding the technology. Plus, the patient had never been mentally competent, so there was no way to honor his request if we didn’t know what it was," the nurse recalls.
The committee determined that the best way to resolve the problem was to apply the benefit or burden judgment, she adds. "In other words, we each asked ourselves if the patient would benefit from the technology, or would it be a burden on his life," she says. "Based on our knowledge of the patient, we unanimously determined that the feeding tube would only discomfort the patient, and we couldn’t justify that, especially to the patient."
The patient without the benefit of the feeding tube improved and was released. He died about six months later in the skilled nursing facility, the nurse says.
Retrospective review: Committee members discussed the case at their next meeting and concluded they acted in the appropriate manner. "The committee felt unanimous in determining that the patient would not benefit from the procedure. Additionally, the committee recognized that the patient was lucky to have a compassionate physician who questioned the appropriateness of a feeding tube," she says.
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