Dealing With Conflict in Caring for the Seriously Ill

Abstract

The Patient's StoryMrs B was an 84-year-old woman with advanced dementia who developed an aspiration pneumonia requiring an acute care hospital admission to the intensive care unit. During her recovery, she had difficulty during an informal swallowing study. To provide nutritional support, her family agreed to the temporary placement of a nasogastric tube, even though she pulled it out twice. Physical restraints were used to prevent further episodes of tube dislodgement. The hospital medical team recommended placement of a percutaneous gastrostomy for feeding. However, based on the patient's previous wish not to end up in the same state as a sister-in-law with Alzheimer dementia, her husband and the rest of her family believed that she would not have wanted a long-term feeding tube, and she was transferred to a nursing home without a feeding tube. The family's hope for her nursing home stay was for her to regain sufficient strength that she could resume oral intake. They were uncertain if rehospitalization would be appropriate at this point in her illness. PERSPECTIVESA Perspectives editor interviewed Mrs B's husband, Mr B, in December 2003, and the medical director of Mrs B's nursing home, Dr Q, in January 2004.MR B: My wife has been bedridden for the past 2 years and during that time has needed special care and caregivers since she has lost the use of both her arms and her legs. In March of 2003, she developed pneumonia, and we took her to the hospital. The doctors repeatedly suggested . . . inserting a gastric tube for nutrition. [This reminded me of] the story of my sister, who had had a gastric tube installed. She died a few years ago, and the quality of her life for years was just nonexistent. She was not really living, and the tube was all that kept her going. We were a little disturbed by the frequency of the calls for the gastric tube. [The doctors were] quite insistent. We indicated that it was just out of the question.DR Q: [When Mrs B was admitted], my understanding was that she was on a do-not-resuscitate status. But, if need be, [she] See also Patient Page.

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