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Spring 2002
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Mental
health
Withholding
Tube Feeding in a Woman with Advanced Dementia
**Benefits
and burdens of artificial nutrition and hydration (tube feeding)
**Terminal dehydration
**The legal and moral
aspects of tube feeding
**Withholding versus
withdrawing life-sustaining treatment
**Vulnerable nursing home
patients
**Do-not-hospitalize orders
Vivian is an 88-year-old woman with advanced dementia, who lives in a
nursing home. As her dementia progressed she was able to take less and
less food by mouth and percutaneous endoscopic gastrostomy (PEG) was
performed for the provision of total enteral nutrition and hydration.
Vivian is now mute, bedridden, incontinent, and completely dependent.
She moans at times, occasionally scratches herself, and pulls at her
feeding tube. Wrist restraints have been applied periodically to prevent
her from dislodging the tube.
Vivian was diagnosed with Alzheimer’s disease nine years ago. Except
for mild hypertension and intermittent pressure sores, she currently has
no other illnesses. In the past three years, however, she has been
hospitalized with pneumonia on four occasions, but she improved rapidly
with systemic antibiotics.
Although Vivian’s niece originally authorized the feeding tube, she is
distressed at her aunt’s condition and now requests that tube feeding
be discontinued, but the nursing home refuses. The niece insists,
stating that her aunt had once said, “If I ever get senile, I hope
they shoot me, “ and that she would never have wanted this type of
treatment in her condition. The nursing home rejects that notion that
this is “treatment” at all; they believe that the feeding tube is
basic care that should be provided, and have a “conscience
objection” to forgoing artificial nutrition and hydration. They
physician sys that not to do so would amount to “starving the patient
to death.” What’s more, the physician points out, the patient has
hypoalbuminemia, pressure ulcers, and a susceptibility to aspiration
pneumonia, making the feeding tube “strongly indicated”.
What ethical and
legal differences exist, if any, between tube feeding and other
medical treatments?
- Would it be possible
to initiate artificial nutrition and hydration and subsequently decide
to withdraw it?
- What accommodation
exists for providers who hold a specific moral objection to
withholding or withdrawing tube feeding?
- What legal
protections exist for dependent institutionalized patients and how
might they affect decisions for Vivian?
- What kind of planning
could have been undertaken for Vivian in the event that she became
acutely ill, requiring hospitalization?
From: Ahronheim JC, Moreno JD,
Zuckerman C. Ethics in Clinical Practice, 2nd Edition.
Aspen Publication, Maryland, 2000.
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Course
Overview