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Mrs. T, and 82 year-old widow with no family and no advance directives, was admi

by | Jun 3, 2022 | Other | 0 comments

 

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Mrs. T, and 82 year-old widow with no family and no advance directives, was admitted to a nursing home from a hospital after a bout of malnutrition, dehydration, and anemia. In the hospital, she had deteriorated mentally because of a multi-infarct dementia and was unable to meet, and disinterested in meeting, her nutritional needs. Even though her decisional capacity was in doubt when she was admitted to the nursing home, because of cost and hassle factors no efforts had been made to adjudicate her incompetent and have a guardian appointed. The facility medical director was serving as Mrs. T’s attending physician.
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Mrs. T was a slight, short, frail woman who at admission to the nursing home weighed 95 pounds in a soaking wet bathrobe. She was pleasant but quiet, preferring to keep pretty much to herself. About a month after her admission, it was noted that she had dropped 5 pounds. She told the nurse she ate “some of the food here,” but that she did not really like the way the nursing home served meals and usually was not very hungry anyway. The nurse told Mrs. T it was important for her to eat and pointed to another resident with a feeding tube, which elicited from Mrs. T a pained expression. The nurse noted in Mrs. T’s chart that she was at danger of malnutrition. The nurse additionally ordered a dietary consult and requested that Mrs. T be offered calorie-rich snacks several times per day.
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Not long thereafter, Mrs. T suffered a seizure and was unwilling to eat even though she was able to swallow. A neurological consultation revealed that she had had a minor stroke. A week later the nurse noted “dysphagia, weight loss, drooping mouth, taking 50% of meals by mouth.” In consultation with the dietitian, the nurse ordered high-caloric shakes thinned with liquid and noted that Mrs. T would require coaxing from the staff to drink the shakes and eat the snacks to be offered to her all day. A month later there was further weight loss of a few pounds, and Mrs. T was still consuming only very small portions and only very slowly, requiring a lot of staff time and attention. The physician concluded that Mrs. T would require insertion of a feeding tube to ensure she received adequate nutrition and so notified the facility administrator. The administrator’s chief concern was that Mrs. T’s weight loss would be a “red flag” receiving special attention from the state surveyors at the next facility survey and that the facility might be cited by the regulators for neglecting a resident’s nutritional status.
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In light of this legitimate regulatory concern, what should be done? Should the feeding tube be inserted? Could a conscious choice not to insert a feeding tube, when the resident is steadily losing precious weight, be justified to the state surveyors? Is there a clash here between legal and ethical principles, on one side, and the facility’s risk management incentives, on the other? If so, what is the best compromise?

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