Feeding Tube Futile?
Rosemary FlaniganMay 12, 2010
An 86-year old woman suffered a massive intracranial hemorrhage, was admitted to the hospital through the emergency room, intubated and then extubated per her wishes in her advance directive. Since suffering her stroke she has been in a persistent coma with no meaningful response to verbal stimuli, only spontaneous movement on the right side and facial grimacing.
The patient wrote an advance directive in 2004 witnessed and talked over with by her son but not discussed in the intervening years. On her form she initialed the life-sustaining procedures she wished withheld or withdrawn if she is in an “irreversible condition as a result of injury, disease or illness, such as extreme mental deterioration and two physicians have certified that her condition is terminal or cannot be significantly reversed.”
Those conditions are: antibiotics, CPR, respirator, radiation, surgery, prescribed medications, chemotherapy, and kidney dialysis. What she DIDN’T initial were artificial nutrition and artificial hydration. When a feeding tube was mentioned, the son agreed saying that, since her advance directive was being followed in other ways, it ought to be followed here, too.
She died with a feeding tube. I support inserting the feeding tube; if advance directives are our moral and constitutional right, then they ought to be followed.
A colleague at the Center makes an excellent argument – the feeding tube ought not have been offered. It is not palliative; it does not benefit her; it is futile.
What do you think?
Labels: medical ethics; medical futility; advance directives
posted by Practical Bioethics at
8:47 AM
4 Comments:
Futile for what purpose? must always be asked. I agree the son of this patient respected the written directive, but was it truly an informed choice? Nutrition and hydration issues should always be discussed, but a clear recommendation should be offered in the context of the goals of care. In this circumstance, the "feeding" tube could not benefit this patient and carries additional risk of harm. The communication should have been unambiguous in an empathic way, recommending that she not be subjected to this invasive procedure on medical grounds.
The terms "futile" and "benefit" need to be used very carefully. Futility technically refers to a condition that "won't work" or serve its intended purpose -- i.e., something that produces no appreciable effect regardless of its use. In this situation, the feeding tube is introducing nourishment, which the patient's body is apparently using. Thus, the feeding tube is not a technically futile treatment. The meaning of "benefit" is much more subjective. If the patient defined "benefit" as "sustaining life" then the feeding tube does provide a benefit. That having been said, the patient has refused a great many other treatments relative to a condition of "extreme mental deterioration." This suggests that she had other worries about foregoing a feeding tube (i.e., hunger, thirst, starvation, etc). While it appears unlikely she will be aware of such symptoms in her condition, she may well have feared them. Was she fully "informed" about the burdens and benefits of feeding tube use? Probably not. Was she aware that feeding tubes are the primary cause of prolonged dying in such situations? Likely not. This case underscores the need for advance directives that focus on health "outcomes" rather than treatment measures. An outcomes-oriented advance directive, such as the Lifecare Advance Directive, for example (see: www.lifecaredirectives.com), minimizes the likelihood of such events. While an individual is supremely qualified to speak to health outcomes in he or she would not want life prolonged, only physicians are qualified to select the treatments and interventions needed to achieve those outcomes -- or to select those treatments needed to maintain comfort when health can no longer be restored.
-- JT McKay, PhD
Well put, Dr. McKay. A further comment: that a decision was made to insert the tube in order to honor the patient's "right to decide" when in fact the AD essentially indicated "No comment" regarding feeding tube, not a "please do it" seems to beg the question. In fact, it would seem a patient who can no longer tell us what she wants is getting treatment BECAUSE she did not specifically refuse it, and BECAUSE we do not know her wishes precisely in this case. My gosh...I shudder to think what might be available when I'm 80 something. How could I possibly put enough detail in an AD to cover EVERY possible option?
Interesting way to redact this kind of information, I'm a specialist in this type of cases, and the intracranial bleeding occurs when a blood vessel within the skull is ruptured or leaks. It can result from physical trauma (as occurs in head injury) or nontraumatic causes (as occurs in hemorrhagic stroke) such as a ruptured aneurysm.
23jj
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