Complicated Medical Decisions

You admit a 78-year-old man with shortness of breath. He is acutely unwell. Investigations reveal that he has right lobar pneumonia. He also has dementia and ischemic heart disease. Despite intravenous antibiotics and fluids, he does not make much improvement over the next few days. He is lethargic, yet occasionally agitated and needs full nursing care. You discuss his medical issues with his wife and son to see how they had been coping at home before the pneumonia. You discover that there had been a gradual decline in his general well-being over the past 6 months. The speech and language therapist now grades him as unsafe to swallow. A nasogastric tube is inserted so that he can continue to be fed but he pulls it out on three occasions. He continues to deteriorate and his albumin drops due to sustained lack of intake. The only way to improve this would be to insert a percutaneous endoscopic gastrostomy (PEG) tube, but you feel that in a patient with so many comorbidities this may not be in his best interest. You discuss the pros and cons of PEG feeding with the patient’s family. You inform them that the medical opinion of the team is to allow the patient to return home but that you would be willing to consider a PEG if the family felt that the patient would continue to have a good quality of life with one.

• What should the medical team’s explanation include for sending him home?
• What treatment option (or no treatment) are they given? Does age play a role in his care?
• What are the pros and cons of PEG feeding?
• Which “voices” should be listened to in this scenario?
• If the son and wife disagree, who makes the final decision? Why?

Apply Theory (Specific Professional Healthcare Competencies + Clinical Medical Ethical Principles) to Practice in order to provide Optimal Patient-Centered Care (OPCC)

Clinical Ethics and Law, Second edition. Carolyn Johnston, Penelope Bradbury, Series editor: Janice Ryme