Case 27 re: artificial nutrition
(Work on Case 21 first)
Answer questions at end of case, using one of your theories. Like the previous case, let's cover all the theories, so just rotate to the next one on a first-come, first-serve basis. As the last 2 people post, there might be some repeat.
The theories: Kant, Utilitarianism, Virtue Ethics, Casuistry, Ethics of Care, Ross' Principles, Principles of Bioethics, Coherence theory.
This time, let's critique each other. Each person pick another post and analyze the response.
Case 27
ReplyDeleteIn the case of Mildred, her condition is at the point where her brain has been destroyed by the stroke, her advanced heart disease and other co-morbidities have left her merely a shell. The question of whether nutrition by means of a feeding tube actually doing any good is one to ask. I think not. If it were, then nutrition alone would keep her alive. This is not the case, since her decline and death is inevitable. Would death be by starvation, as the physician states for his grounds of argument, or rather the combination of her collective diseases; heart failure, diabetes, stroke- all which have left her with paralysis and brain death? These conditions have led to her inability to eat, this does not mean her death is caused by starvation if she is not artificially fed, but by the collective condition of her body. As each major organ shuts down when imminent death is near, how much importance is nutrition at this point?
In answering the questions, I use the Principles of Bioethics as my theory point. The four principles for ethical decision making are Autonomy - Respect others
Beneficence - Do good
Non-maleficence - Do no harm
Justice - be fair
Question 1. To withhold nutrition in this case is to remember to do no harm. Non-maleficence, in this case may look different, if you remember that continuing on with artificial nutrition in this case may be doing the body more harm than good, as the body is required to take the influx of tube feeding and process it through the GI system as a well body would. This is not helping, but hindering the body's ability to shut down and die, what it is trying to do anyway.
Question 2 The family has the right to make a decision for the patient since, in her present state, she is unable to make decisions for herself. This is doing good, beneficence, to their loved one; and being fair, justice, to all that is involved.
Question 3 The patient had indicated prior to her present state her wishes to not be resuscitated. This falls under that realm of decision, and should be respected. The doctor should acknowledge this and respect her wishes; a principle of autonomy.
Gloria, I think you make an excellent case and I respect your points very much. However, as part of our required assignment noted above to pick another post an analyze, I disagree.
DeleteBased upon The Principles of Bioethics:
1) To withhold nutrition from Mildred does not meet the non-maleficence principle. It will actually do her more harm. It, ultimately, will kill her. While she has had a major stroke, she is still alive, that stroke did not kill her, and stroke will not kill her unless she has another major stroke. She also is not noted as being brain-dead. She's actually breathing on her own, and is listed as "semi-comatose". While it would be helpful to know more about her neurological status, we do know she does have brain function or she would not have a respiratory drive, and she would be completely comatose and on the vent if she didn't and hadn't instituted a DNR. Since she had a DNR, had she been brain-dead, she would have died. Withholding her tube feeds actually violates the principle of Beneficence. Starving someone does them good in no way. It will actually cause her to dehydrate, have electrolyte imbalances, go into renal failure, and much more.
2) Allowing the family to make a decision about withholding care the patient had not said she wanted withheld is a direct violation of the principle of autonomy. This is not Mildred's decision. She did not say she didn't want feedings and hydration and basic care, she said she did not want to be resuscitated; she didn't want her breathing supported mechanically and did not want her heart restarted. To have tube feedings withheld, she should have had a Living Will drawn up.
3) Justice would not be done if they took her DNR wishes and translated them to assume she didn't want to be fed. That is an assumption we cannot make and be fair to that patient.
Case 27
ReplyDeleteIn the case of Mildred, her condition is at the point where her brain has been destroyed by the stroke, her advanced heart disease and other co-morbidities have left her merely a shell. The question of whether nutrition by means of a feeding tube actually doing any good is one to ask. I think not. If it were, then nutrition alone would keep her alive. This is not the case, since her decline and death is inevitable. Would death be by starvation, as the physician states for his grounds of argument, or rather the combination of her collective diseases; heart failure, diabetes, stroke- all which have left her with paralysis and brain death? These conditions have led to her inability to eat, this does not mean her death is caused by starvation if she is not artificially fed, but by the collective condition of her body. As each major organ shuts down when imminent death is near, how much importance is nutrition at this point?
In answering the questions, I use the Principles of Bioethics as my theory point. The four principles for ethical decision making are Autonomy - Respect others
Beneficence - Do good
Non-maleficence - Do no harm
Justice - be fair
Question 1. To withhold nutrition in this case is to remember to do no harm. Non-maleficence, in this case may look different, if you remember that continuing on with artificial nutrition in this case may be doing the body more harm than good, as the body is required to take the influx of tube feeding and process it through the GI system as a well body would. This is not helping, but hindering the body's ability to shut down and die, what it is trying to do anyway.
Question 2 The family has the right to make a decision for the patient since, in her present state, she is unable to make decisions for herself. This is doing good, beneficence, to their loved one; and being fair, justice, to all that is involved.
Question 3 The patient had indicated prior to her present state her wishes to not be resuscitated. This falls under that realm of decision, and should be respected. The doctor should acknowledge this and respect her wishes; a principle of autonomy.
great way to state your case Gloria!
DeleteVery valid points Gloria! To critique and analyze your post however, my answer to question one is very different than yours. I feel like non-maleficence, or to "do no harm" in this case would be related to starving the patient. I agree artificial nutrition could possibly do the body more harm than good, but the case doesn't specify that aspect, only that the nutrition would be prolonging life. So I look at it as the decision is to either starve the patient to death (doing harm) or not starving him to death (doing no harm).
DeleteIn response to question two and three, I would have to argue the point of is it really doing the patient good or being fair when we don't truly know the patient's wishes in regards to artificial nutrition?
Well stated Gloria.
Delete1. It is morally legitimate to withhold the tube feeding. The patient has a history of heart disease, two heart attacks, diabetes and now a stroke that has rendered her paralyzed and un-responsive. Tube feeding is for otherwise healthy people who can process the nutrition. Mildred's body is trying to shut down and die. Pumping her full of tube feed can result in residual and possible aspiration from not absorbing the feed as an otherwise healthy person would. Stopping the feed will allow for a peaceful death that isn't complicated by aspiration pneumonia. Mildred is not going to "starve" to death. Her death will be due to the stroke.
ReplyDelete2. They family does have the right to make decisions for Mildred. Mildred has been incapacitated by the severe stroke and can no longer make decisions for herself. She had expressed her wishes to the family when she was autonomous.
3. The refusal of resuscitation is the refusal of CPR or artificial ventilation. Mildred cannot eat and would be artificially given nutrients via an NG. Nasogastric tubes can be very uncomfortable and artificial feeding can be painful if the feeding is not being absorbed and the stomach is distended due to the un-absorbed feed. I think the nutritional feeding should be considered on a case by case basis. In this case, I think it would be in the best interest of the patient to stop the feedings.
I based my answers using the utilitarian theory. We will maximize the good and decrease the unhappiness for the greatest number. Mildred will be more comfortable without the tube feed and allow to die naturally. Mildred's family will be happier knowing they are following her wishes, even though it may be a slow death.
Tracy I agree with your ideas regarding the tube feeding, but when feelings are set aside I cant say with certainty that the patient would specifically decline tube feedings. Declining to have someone restart your heart is different than allowing a tube to provide nutrition. With that being said, doing so would be supported by the utilitarian theory which I totally agree with.
DeleteI think you can't starve a patient but I do see some of your points by feeding her could cause her to aspirate and suffocate to death. The nurse side of me would never want to be given nutrition when I'm essentially a vegetable.
DeleteI admire some of your points Tracy. My original thoughts were of starving the patient, however you make a very valid point of doing more harm with it.
DeleteWhen considering Ross' principles in regards to this case it may be considered that the withholding of nutrition is unethical. not caring for the patient to the full extent of our capability goes against the prima facia duties of non-injury, Harm-prevention and beneficence. Ross states that we must uphold these duties "unless stronger moral consideration override." (people.eku.edu 2004)
ReplyDeleteWith all of this being said, I feel that the wishes of the family and patient are a "stronger moral consideration."
1) I am not sure that it is morally legitimate, the patient expressed her desire to not be resuscitated, however she did not say that she wanted action taken to help her die. essentially, that is what would be happening here. Given the opportunity, I would imagine she would express her desire to not want tube feedings and prolonging of life.
2) I do feel that it is the family has the right to make decisions for the patient. the family has legal permission to make these calls and knows the patients wishes better than most.
3) a refusal of resuscitation is not a refusal of nutrition, as previously discussed. In some cases, however not this one, the patient could live a version of a productive life with the assistance of nutrition. when it comes to ethics I believe it is a case by case decision.
The one area I feel we may differ is the family's right to stop nutrition from the patient. I think that defining rights of what a family can and can't do is very blurry and I feel this could go either way.
DeleteYes, these are definitely the grey areas. I believe the family has that right when the patient cannot speak on their own behalf. I think in this case there are pros and cons to both sides.
DeleteUsing Ethics of care I believe it is unethical to hold nutrition because ethics of care is about what is morally right and morally wrong.
ReplyDelete1. The patient never said in anytime when she was coherent that she didn't specifically want a feeding tube. She said she didn't want life saving measures to be used. So morally no it wouldn't be right for them to discontinue nutrition.
2. I don't believe the family has the right to do this they didn't discuss with the patient about what she would want and it is a very in humane thing to do. I believe the family had the right to make a lot of decisions but hold nutrition making the choice to starve her to death is wrong.
3. Refusal of resuscitation shouldn't also be taken for as refusal of nutrition they are completely different things. If I was a DNR and I got a throat cancer and couldn't swallow anymore but I could survive for years if I had an Ng or feeding tube it would be ridiculous for to just starve to death just because I was a DNR. Once again a DNR doesn't mean don't treat.
Alex: all our theories are about what is morally right & wrong. What's the basis for ethics of care? Spell it out more deliberately.
DeleteGood example!
DeleteAlex I do agree with your comment regarding that you would want a feeding tube if you had throat cancer and was unable to eat. That is completely reasonable. I treat people in these types of conditions frequently. They are fully aware of receiving a peg tube for their nutrition, and administer their own feedings. But, the case of Mildred is completely different. Her total condition is deteriorating from her co morbidities of Diabetes, Heart attacks, and a major stroke. Tube feeding is not likely to help her in any way to 'get better' or 'live better'. It could possibly allow her shell of a body to stay alive longer. The feedings could cause more harm than good, as the body would be required to process it. As Tracy mentioned, a very high risk of aspiration or distention causing more discomfort. Starvation is no longer the issue, her death would be from the stroke, not lack of nutrition.
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ReplyDeleteKant theory which focuses on good will being the only thing that is unconditionally good. Good will can be seen as an action that can only be good if its principle behind it is good.
ReplyDelete1. I don't think morally legitimate to withhold the tube feed/nutrition. I can see how the physician would think it is unethical to stare the patient. Even though the patient did not want to be rescucitated. The nutrition is not resuscitation. Unless the tube feed was discussed previously as a life saving treatment she did not want. She also did not say she wanted to be deprived of basic needs as well.
2. I do believe the family has the right to make such decisions. First the POA then next of kin. After they have been fully educated regarding both sides they can then collaboratively make the choice.
3. I do not think the DNR should be considered when taking it for what it actually means. Does not clearly state that she did not want supplemental feeding in her advanced directives.
Agreed. We deal with this on a daily basis. Actually, our physicians are pretty good about it. Working in the ICU, most of our patients need to be started on some sort of nutritional supplement while they are with us. We have a dietician that actually rounds everyday and speaks with families that we are getting ready to do start feeds, they educate the family that this is not something that is addressed with just code status. Now if they have a living will then we obviously respect that, and if it states that they do not want any artificial feedings then we do not go against that. But the majority of families and physician are all on the same page and its all about just educating about what these terms mean.
Delete1)Is it morally legitimate to withhold nutrition in this case?
ReplyDeleteWith the application of Virtue Ethics, it is not morally legitimate to withhold nutrition in this case. The physician has to ask himself “What kind of person should I be to do what is moral for my patient”. Allowing a patient to starve to death because they are now physically paralyzed and “semi-comatose” is not a moral thing. The case does not state the patient is brain dead. Mildred D. has a respiratory drive of her own, and her brain is not affected to the point she cannot breathe on her own. Mildred D.’s heart is beating on its own. Practical and clinical experience tells us that starving to death is slow and painful, and Mildred D. has no chance to survive without nutrition. If Mildred D. is starved, she will experience a negative nitrogen balance, and physical conditions that cannot be prevented in the presence of this will follow. She will develop bed sores, her flesh will start to decay while she breathes and it will have no chance to heal. She could only hope the electrolyte imbalances would kill her before she decays while she is alive. Does this sound like the kind of person a health care professional should be for their patient?
2)Does the family have the right to make such a decision for the patient?
While the family is trying to make the decision they feel is best for Mildred D., no one can know what her level of suffering or quality is. As she lives “in the twilight zone”, and this seems dismal with no quality of life to her family, she might be traveling the world in her twilight zone. In her mind, she might finally be on the trip to Italy she had always dreamed of taking, or she’s traveling around the world. Or even more thought-provoking, people talk of their out-of-body experiences in which they go to another realm, and they see Jesus or loved ones who have passed. Mildred D. might be in her out of body experience during this time, she is on a spiritual voyage in another realm that only she and her God know about. When He is finished with her, and Mildred D. is finished with her voyage according to His time, her God will end her time her on earth. She is still breathing without assistance, her heart is still beating on its own, and her time here is not finished according to her Maker. Although the family believes they know what is best for her and ending her suffering, they only see one dimension of where Mildred D. is in her journey here, she might not be suffering at all wherever she is in there. She might be walking on a golden beach with her God and her loving husband who left her 20 years before.
3)Should the refusal of resuscitation be considered as an indicator that the patient would also refuse nutrition?
Refusal of resuscitation does not imply the desire to not be nourished. Resuscitation encompasses what to do when a person stops breathing or their heart stops beating. When people decide to institute a DNR on themselves, they are thinking “I don’t want to have a breathing tube and be on a machine if I quit breathing” and “I don’t want you beating on my chest and shocking me if my heart stops”. Part of virtue ethics is it needs opportunities to be tested and refined. Years of healthcare practice has told me most times when people say they do not want breathing tubes or their “heart restarted”, if you ask them do they want to be fed via enteral nutrition if needed, they say yes. We cannot assume Mildred D. did not want feedings. She said she did not want resuscitation, as she was thinking about the critical picture of no respirations/ no heartbeat. Had Mildred D. thought about feedings and other treatment, she would have needed to institute a Living Will to make her desires clear.
Brand-Ballard, J., Degrazia, D., Mappes, T. (2011). Biomedical Ethics 7th ed. pg. 402-404. New York, NY. MCGraw Hill.
Shelley,
DeleteOnce again you state your case eloquently and fully. As I do agree with your points, I have to find some way to critique you. So my critique would be on question number 2. If Mildred is having her journey with her husband on a golden beach while she is in this vegetative state, wouldn't it be feasible to believe that once she does pass would she not be taking that same stroll, holding hands with her husband? In the current state that she is in, we can not tell with certainty if she is in pain, suffering or taking a journey. I'd like to think shes in Italy though :)
That's a good question, Jocelyn. (I was having a near delusional moment up there, wasn't I? ;) I don't know. I guess that's what I'm saying, we don't know timing. I just feel like God has a plan for all of us. If his plan had been for Mildred to come with him at the time of her CVA, he would have taken her then. If we withhold essential care to rush things along, we might mess up His timing.
DeleteInteresting thought process Jocelyn! I have often wondered if and what patients in this condition think or dream of or is it truly a "vegetable" state. The mind, body, and soul are such amazing phenomenons that I don't think we will every truly understand.
DeleteThat's exactly what I was trying to say above, Erin... How do we know? It's so unsettling to think about us thinking we know what's going on in their minds (being nothing), and really there might be something major going on in there.
DeleteFor this case I will be using casuistry, case based reasoning.
ReplyDelete1. Is it morally legitimate to withhold nutrition in this case? I don't believe that it is morally legitimate to withhold nutrition. Mildred never legally made her last wishes or DNR known, she just indicated to her family that she does not wish to be resuscitated. It may be a long and drawn out ordeal that no person should be submitted to, whether she is coherent or not.
2. Does the family have the right to make such decisions for the patient? It does not appear as if the patient made any formal advanced directives. This may be a time when case law is looked at. For example, in the case of Terry Schiavo there was a successful petition for termination only after a diagnosis of persistent vegetative state was made (Wikipedia, 2016). The physician and family must sit down and discuss all of the factors surrounding this patient's case. Are there any cases where a patient displayed similar medical circumstances and pulled through to make a recovery?
3. Should the refusal of resuscitation be considered an indicator that the patient would also refuse nutrition? Again, this is a time when looking back on previous cases and examining if there are any laws present that define what resuscitation measure are. The medical definition of resuscitate per the Merriam-Webster dictionary is to revive from apparent death or from unconsciousness. If there are no legal advanced directives in place then the family should be be the ones to make medical decisions. If they feel as though this would be what she wanted and what she meant by no resuscitation, then they would have that right.
Excellent application to a real case familiar to many of us. I remember all the coverage on that, it was truly a terrible case all the way around. I don't think there's a winning situation anywhere in the case of Terry Schiavo or Mildred D.
DeleteEveryday I see it way too often, patients need to consider an advance directive in order to state their wishes. This will take care of the "un-known" when something like a CVA occurs. The family and physicians will know the wishes of the patient. Having an advance directive takes away the pain of the family having to make difficult decisions.
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ReplyDeleteAccording to the theory of coherence, no level of ethical conviction deserves priority. Basically, all cases need justification. The three requirements for coherence theory are logical consistency, argumentative support, and plausibility, these areas all need to be considered. In the case of artificial nutrition, the answer to question one, (is it morally legitimate to withhold nutrition?) would need to be looked at from both sides. The doctor and the family both have valid arguments. Logically, the patient would "starve" to death which is an obvious contradiction to prolonging the patient’s life with feedings. . Argumentatively, the doctor's reasoning for his decision is backed up by his statement of being ethically wrong to starve his patient whereas the patient’s family is backing up their decision with the fact of stating the patient’s prior wishes. . The doctor has a plausible reason as does the family for their decisions. If a DNR with advanced directives had been in place this situation could have been avoided. Using this theory, I don’t feel like a clear yes or no answer can be reached to the question of whether or not it’s morally legitimate.
ReplyDeleteThe answer to question number two (does the family have the right to make the decision) also needs to be looked at from both sides according to this theory. Again, I don’t feel like using this theory would provide a clear yes or no answer. The same principals could apply that I mentioned earlier.
The third question of should the refusal of resuscitation be considered an indicator that the patient would also refuse nutrition I feel like does provide a clear answer if using this theory which would be no. Logically, there are obvious contradictions such as the family’s wishes versus the doctor’s ethical standard. Argumentatively, one cannot assume this is what the patient would have wanted. Therefore, the indicator would not meet the requirements of this theory.
I think you did a wonderful job applying the case to this theory.
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