TUBE FEEDING AND RESIDENT RIGHTS

Tube Feeding and Resident Rights



Tube Feeding and Resident Rights

Introduction

In critical care medicine we use a high-technology care plan to reverse organ system failure. Sometimes, however, organs can only be brought back to nominal function, creating dependence on others to supply sustenance. If these patients had never expressed a clear preference to be allowed to die in such circumstances, then their surrogate's preferences may conflict. We examine the aftermath of a case of a patient in a persistent vegetative state (PVS) whose surrogate conflicts lead to legal complications.

The case

Following an anoxic insult, a 30-year-old female patient resides in a nursing home for 2 years without any evidence of meaningful neurologic recovery. There is some controversy regarding the extent of her brain damage; some doctors have diagnosed her as being in a PVS whereas others disagree. It is agreed that she suffers severe neurologic deficit. At baseline she opens her eyes and appears to track family members; she smiles but she does not follow commands. She is hemodynamically stable and is sustained by a feeding tube. There is no living will. Both the husband and family state that the patient has never volunteered an opinion regarding end-of-life issues in the past, apart from one occasion when she casually mentioned that she would not ever want to 'live like a vegetable'.

Her husband petitions you to remove the feeding tube and 'let my wife die with dignity'. However, her family says that the patient responds to them and they do not feel she is in any discomfort. The family opposes removal of the feeding tube. The patient's mother appeals to the State to intervene and stop any attempt at removal of life support on humanitarian grounds. The current law of the State she resides in is that there must be 'clear and convincing' evidence of a patient's wishes before life-sustaining treatment (LST) can be removed from that patient.

Would you remove the feeding tube?

Being law abiding and ethical

This is both a legal and an ethical issue. It is required that doctors obey the law. The law of the State in which this patient's resides is that there must be clear and convincing evidence of the patient's wishes before life support can be removed from that patient. I suspect that in these circumstances the feeding tube may be defined as life support. If we can almost consider patients' wishes in terms of levels of evidence, then we would class the evidence for removal of the feeding tube being in keeping with the woman's wishes as the lowest level of evidence, as opposed to the best evidence, namely an appropriate written directive by a well patient. As with all expressed wishes by whatever means, it is often difficult to determine their relevance to the prevailing situation. Did the patient's casually expressed wish - stated when she was not suffering - disclose her views regarding artificial feeding?

It appears to me from the information given that the feeding tube may not be removed because this ...