An 82-year-old patient with severe dementia has been admitted to our extended-care facility. He has an advance directive declining heroic measures, and his son has durable power of attorney for health care.
The patient can no longer eat and his son has refused to allow a gastric tube to be inserted. The patient's physician has ordered comfort care only.
In our facility, several patients with dementia receive tube feedings. Do you think the son made the correct decision?—P.S., ILL.
Not only do I think the decision was the correct clinical call, but I also think it was the “right” one ethically. Although providing artificial nutrition can prolong survival in patients who are in a persistent vegetative state, the treatment hasn't been shown to prolong survival in patients suffering from advanced dementia. Your patient's son has made a courageous and compassionate decision.
I recall a heated ethics referral involving an unresponsive patient who'd been admitted to the hospital after a devastating stroke. He'd written a clear and concise advance directive refusing heroic measures, including artificial hydration and nutrition, if he couldn't speak for himself and had no hope of recovery. He'd also given his longtime companion, Rosemary, durable power of attorney for health care so she could speak for him in such circumstances.
The perfect surrogate, she reiterated his wishes—no I.V.'s or artificial nutrition—only to find herself attacked by a physician. “Well, he's not going to die today!” he said. “You don't want him thirsty, do you? Or starving to death?”
Fortunately, Rosemary had done her homework and refused to be intimidated. “I'm not a doctor,” she said firmly, “but if he can't even follow commands, then I don't see how his brain could process feeling hungry or thirsty. He made his wishes clear, and they should be respected.”
The exasperated physician stormed out of the conference room and asked to be removed from the case.
Fortunately, a physician on the ethics committee agreed to take over and the patient's wishes were honored. He was treated with comfort measures only and died peacefully a few days later.
Your patient has made a similar decision about end-of-life care. By providing comfort care, you honor his right to refuse futile treatments.
Joy Ufema pioneered the role of death-and-dying specialist at Harrisburg (Pa.) Hospital in 1973. She's currently clinical specialist at Upper Chesapeake Medical Center in Bel Air, Md., and at Harford Memorial Hospital in Havre de Grace, Md.
Feeding tubes in patients with severe dementia, American Family Physician
, I Li, April 15, 2000.