2015: tube feed or not tube feed?-heidenreich
TRANSCRIPT
TUBE FEED OR NOT TUBE FEED?
Robyn Heidenreich, MDRuth Lee, MDUCSD Geriatrics SymposiumOctober 24, 2015
Background on Patient 90 year old female patient with:
Dementia, Alzheimers Acute stroke, February 2015 Diabetes Chronic kidney disease stage 3 Hypertension Atrioventricular block, second degree s/p
pacemaker She was living at board and care. She was
able to feed self and use toilet on own, and was ambulatory.
Medications Glipizide Plavix Lipitor
ER - 7/11/2015 Brought to the ER for rectal bleeding and abdominal pain CT findings showed pneumatosis intestinalis of distal
sigmoid/rectum Prior to ex lap, the surgeon discussed poor prognosis
with daughter. Palliative care was offered, but daughter reported that patient would want “absolutely everything done.”
During the ex lap, patient was found to have necrotic/perforated rectum with feculent peritonitis. She underwent laparoscopic sigmoid colectomy with colostomy. She was admitted to Intensive Care Unit after surgery for management.
Hospital Course In the ICU, patient was extubated
successfully, but remained septic and did not return back to baseline.
Advanced Directives Social worker was consulted. It was
noted that there was no DPOA or healthcare directive noted in chart. There was a POLST form dated 09/03/12, which was signed by the patient's daughter and indicated FULL code. It was also noted that daughter had stated that she had legal DPOA (unclear if medical or finances); however no paperwork was provided.
Disagreement among Family Members
The patient’s son expressed concerns about his sister’s ability to make sound medical decisions on the patient's behalf.
He stated that his sister was an Orthodox Jew, and he felt that she was making medical decisions based on her own personal religious beliefs and not those of the patient.
He reported that the patient was a Holocaust survivor and described her as "culturally Jewish“, but that she did not have strong religious convictions.
He believed that his mother should be DNR, and that she should never had undergone surgery in the first place.
Bioethics Consulted At this point, bioethics was consulted. The goal of a bioethics consultation is to
help those involved reach a moral understanding that promotes the good of the patient.
Bioethics was Consulted Bioethical Issue: Surrogacy issue(s): The patient's
daughter has been making decisions and providing consent. She presents a POLST form, and states that according to family religion, they would want maximal treatment including full code. The patient's son states that medical treatment is too aggressive and against the patient's values. The daughter is apparently DPOA but we have no paperwork to support this claim.
RECOMMENDATIONS:I recommended clarification of DPOA and have daughter bring in appropriate documentation.
Tube Feed or Not Tube Feed?
During the patient’s hospital course, the issue of artificial feeding came up. The internist discussed possible PEG placement with daughter, who was in favor of artificial feeding. However, the daughter wanted to confer with her Rabbi first before making a decision.
Bioethics Follow Up Daughter brought in a DPOA form from 1993, which
identified the patient’s daughter as her primary surrogate and her son as the alternate surrogate.
The document goes on with a statement in the patient's own writing, reflecting her strong wishes against resuscitation and prolonged feedings/hydration in the event of illness from which she would have no reasonable chance for recovery.
She also identifies mental incapacity and coma as conditions under which she would not choose to be supported medically.
Differences in Opinion Among Family Members However, the daughter continued to state that her
mother would want "everything done“, because she has always been a survivor. The daughter continued to reference traditional Jewish religious philosophy as well as the patient's own experience as a Holocaust survivor. The daughter, when asked directly, did admit that her mother did not practice Orthodox Judaism.
Furthermore, the daughter expressed hope that her mother will make a full recovery and get back to baseline. She also expressed hope that as soon as tomorrow there would be a cure for Alzheimer's Disease.
Differences in Opinion Among Family Members Meanwhile, the patient's son continued to express that his mother
would not want "everything done“, because she was not an Orthodox Jew and lost much of her faith as a result of the Holocaust.
He was concerned that his voice as a surrogate had not been considered in her care up to this point.
He was worried that his sister was applying her own principles as an Orthodox Jew when it came to making health care decisions for their mother. This included consulting with a Rabbi, and forwarding documentation from the Rabbi to corroborate her decisions.
He continued to express that his mother would not have wanted the kind of surgery she had. Furthermore, she would not have wanted to continue in her current condition.
Bioethics Recommendations Recommendations: 1. Surrogate for this patient - I informed the two surrogates that
despite the DPOA form, it is up to the medical team to make recommendations and treatment decisions that are consistent with the patient's values and goals. This may include choosing the surrogate that best represents the patient's values and also satisfy the criteria for being an appropriate surrogate according to hospital policy. I emailed a copy of our policy to the team physician. More specifically, I made it clear to the medical team doctor that the patient is not Orthodox Jew and surrogate decisions for the patient should be made based on her previously expressed views and values as clarified through our discussion. This may involve selecting her son to make surrogate decisions if the daughter seems to be making decisions contrary to the patient's values. In such case, Legal may need to be notified if son is selected as the primary surrogate in conflict with the patient's Durable POA documentation.
Bioethics Recommendations 2. It is my recommendation that the patient
should be DNR if medically indicated as per her advance directive (which I placed in the chart). This has already been ordered by the team physician.
3. If a gastrostomy feeding tube or prolonged tube feedings are deemed to have no medical benefit considering her advanced dementia and deconditioning they should not be offered by the medical team. The patient's values in her DPOA form clearly state that prolonged feeding in a state where there is no reasonable chance for recovery is not acceptable.
Tube Feed or Not Tube Feed? Even after the bioethics consultation, the daughter
continued to request PEG tube placement. However, the son disagreed with the PEG tube
placement and agreed with the internist’s plan to have a maximum of 2 weeks trial of tube feeding.
The internist continued to write in his progress note:Daughter, who is current DPOA, does not appear to be acting in patient's best interest as explicitly documented in patient's Advanced Directives. Daughter is current DPOA but son's decisions are more consistent with patient's expressed wishes. Will coordinate to have bioethics, IPC involved again.
Bioethics Consult Follow-Up The medical team has advised against gastrostomy tube
placement and long term tube feeding in this patient on the basis of non-beneficial treatment. Additionally, the process of tube feeding would be against the patient's wishes as dictated in her DPOA documentation. The patient's daughter (primary DPOA) opposes this recommendation when approached with the decision today. Her son (secondary DPOA agrees with the decision).
Medical decision aside, the patient's daughter is clearly basing her reasoning on values that are inconsistent with the documentation and apparent values of the patient before she contracted dementia. More specifically, the patient outlined that she would not want prolonged tube feedings if her prognosis was poor ("beyond a reasonable recovery").
I have advised the treating physician, if he believes tube feeding is inconsistent with the patient's beliefs and values and there is no medical benefit, to initiate the process of invoking the Non-Beneficial Treatment Policy.
Bioethics Recommendations1. The medical team should achieve consensus from all relevant providers that tube feeding is non-beneficial in this patient. This includes the surgery team and any other associated consultants. 2. A family meeting should be held to present the information/decision to the patient's family formally as well as inform them of process. 3. If there is still a challenge to the medical decision, then a second opinion not associated with the primary medical team can provide a second opinion. 4. If the Ethics Review agrees that the process is appropriately followed and that the treatment is non-beneficial, the medical team will assist in transfer of the patient to another facility.
Non-Beneficial Treatment Policy
Tube Feed or Not Tube Feed?
As directed by the bioethics recommendation, the primary internist wrote in his progress note that he would not recommend long-term tube feeding and G-tube placement as it would be non-beneficial treatment as outlined in the hospital policy on Non-Beneficial Treatment.
Second Opinion from Internal Medicine as directed by Bioethics Recommenation: Tube Feed or Not Tube Feed?
I concur that patient clearly expressed in her written advanced directive that she would NOT want any long term artificially life sustaining treatments.
The current treatment plan for the patient is to continue temporary NGT feeds and medications for a defined time trial of 2 weeks in order to determine if after that time whether or not the patient would require long term tube feeding to artificially sustain life.
In my opinion, the placement of a long term feeding tube ( PEG ) or ongoing tube feedings ( NGT ) for more than the stated 2 week time trial would be NON-beneficial to the patient and would NOT be congruent with the patient's written Advanced Directive.
Third Opinion from General Surgery as recommended by Bioethics Recommendation: Tube Feed or Not Tube Feed? Given patient's expressed desires stated in her Durable
Power of Attorney for Healthcare, I feel that prolonged NG TF and/or the placement of a PEG tube would be considered non beneficial treatment. Performance of either would be contradictory to her expressed desire in her Durable Power of Attorney for Healthcare document. Doing so would artificially prolong her life against her stated wishes.
I agree with the current plan for a temporary trial of 2 weeks use of NG tube feeding for alimentation and medications.
In addition I feel that her document further indicates that she would not want re-operative intervention should such be necessary.
Skilled Nursing Facility The patient eventually was discharged to
a skilled nursing facility for rehab. During her stay at SNF, the geriatrician
abided by the decision to have two week trial of tube feeding. He did not change the plan/decision regardless of the daughter’s insistence.
Skilled Nursing Facility During the night, the covering physician
sent the patient to the ER as the patient was short of breath and desatting to the 80s.
In the ER, she was found to be in sepsis secondarily to an intra-abdominal abscess seen on CT.
Skilled Nursing Facility When the primary geriatrician came in to work
the next day, he found that the patient was transferred to the ED.
He held a family meeting and discussed goals of care and offered home hospice care.
The daughter did eventually elect for hospice care.
The geriatrician spoke with the admitting physician over the phone, and patient was sent out on home hospice instead of going through invasive procedures.
Home Hospice Care Patient passed away on home hospice
three days later after discharge from ED.
Timeline Hospitalized from 7/11 – 7/30 SNF from 7/30 – 8/10 ED from 8/10 – 8/12 Home hospice from 8/12 – 8/15 Passed away 8/15
Tube Feed or Not Tube Feed? Do you agree with how the situation was
handled? Would you have done anything
differently? And if so, what?
Tube Feed or Not Tube Feed? The American Geriatrics Society does not
recommend percutaneous feeding tubes in patients with advanced dementia. Instead, it recommends to offer hand-feeding.
It has been shown that hand-feeding patients with severe dementia has the same rate of death and aspiration pneumonia as patients who are tube fed.
Tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.
Bioethics Issues of this Case Advance directives Surrogacy Taking off surrogate / Best interest Futility / Non-Beneficial Treatment
Advanced Directives Advance directives (ADs) are the documents a person
completes while still in possession of decisional capacity about how treatment decisions should be made on her or his behalf in the event she or he loses the capacity to make such decisions.
They are legal tools meant to direct treatment decision-making and/or appoint surrogate decision makers.
The primary instruments that serve as AD documents are:1. Durable Power of Attorney for Health Care 2. Living Will (LW) 3. Other documents such as POLST (Physician Orders for
Life Sustaining Treatment)
Advanced Directives Durable Power of Attorney for Health Care — A Durable
Power of Attorney for Health Care (DPAHC, Health Care Proxy, or Healthcare Power of Attorney) is a signed legal document authorizing another person to make medical decisions on the patient’s behalf in the event the patient loses decisional capacity
Living Will — The Living Will (LW) is a document summarizing a person’s preferences for future medical care. The typical LW takes effect if the person is terminally ill without chance of recovery. Typically, the LW addresses resuscitation and life support; however, a thorough LW may cover patients’ preferences regarding hospitalization, pain control, and specific treatments he or she may require in the future.
Advanced Directives Physician Orders for Life Sustaining
Treatment — Advanced care planning is most effective when it is part of a coordinated effort involving physicians, patients, paramedics, nursing homes, and emergency rooms. A model initiative for such a directive is the Physician Orders for Life Sustaining Treatment (POLST), which delineates what specific care should be administered or withheld at the present time for a specific patient, as directed by a physician.
Surrogacy When patients are unable to voice their
own decisions, we look to people in their lives who can provide guidance based on either their knowledge of the patient’s wishes (substituted judgments) or on their understanding of what is in the patient’s best interest.
They cannot decide to allow patients to suffer unnecessary pain when it can be safely treated.
Problems with Surrogates If patient’s wishes are unknown to the surrogate If the surrogate lacks decision-making capacity
themselves The clinician knows or believes the surrogate is
not acting in accordance with the patient’s wishes The surrogate has difficulty or is unable to make
an informed decision related to the best interest of the patient
The surrogate’s decision may be in conflict by others in the patient’s life (friends or family members)
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Ethical/ Legal Norms: Surrogate Decision-Making Standards
Known wishes Substituted judgment
Best interests
Known wishes sometimes
require clarification,
therefore become “substituted judgment”
Knowing a patient does not always result in
knowing their preferences
What if there’s no assigned surrogate?
California law does not provide a hierarchy of decision makers Next of kin is understood as family Can also include friends or neighbors Law explicitly permits domestic partners Physician to identify best decision maker
Ethical/ Legal Norms: Decisional Capacity
When Should A Physician Turn to a Surrogate?
When patient loses decisional capacity Ability to understand Ability to deliberate
based upon values, beliefs and recognize consequences
Ability to communicate response
What Should We Know about Decisional Capacity?
Decision-specific Can be intermittent Not the same as “legal
incompetence” Cognitive impairment does
not = lack of capacity Depressed patients do not,
by definition, lack capacity Can use consultants
(social worker, psych, ethics)
Best Interests The surrogate should evaluate treatments by
balancing the benefits and risks and select those treatments in which the benefits maximally outweigh the burdens of treatment
Legally, this standard is considered "objective" because it does not rely on imagining what the patient would choose but rather on some externally defined standard
Deciding what constitutes a benefit or burden seems to depend on a patient's personal values.
Futility Strict definition: physiologic impossibility of an
intervention achieving its therapeutic objective More expanded view may include interventions
that fall below a specific standard Example: dialysis filling in for failing kidneys, but
likely won’t contribute to returning the patient to an acceptable overall health status
Should not be used to discourage families from insisting on treatment that care providers consider inappropriate