Tube Feed or Not Tube Feed?

1. TUBE FEED OR NOT TUBE
FEED?
Robyn Heidenreich, MD
Ruth Lee, MD
UCSD Geriatrics Symposium
October 24, 2015

2. Background on Patient
 90 year old female patient with:
 Dementia, Alzheimers
 Acute stroke, February 2015
 Diabetes
 Chronic kidney disease stage 3
 Hypertension
 Atrioventricular block, second degree s/p
pacemaker
 She was living at board and care. She was
able to feed self and use toilet on own, and
was ambulatory.

3. Medications
 Glipizide
 Plavix
 Lipitor

4. ER - 7/11/2015
 Brought to the ER for rectal bleeding and abdominal
pain
 CT findings showed pneumatosis intestinalis of distal
sigmoid/rectum
 Prior to ex lap, the surgeon discussed poor prognosis
with daughter. Palliative care was offered, but
daughter reported that patient would want “absolutely
everything done.”
 During the ex lap, patient was found to have
necrotic/perforated rectum with feculent peritonitis.
She underwent laparoscopic sigmoid colectomy with
colostomy. She was admitted to Intensive Care Unit
after surgery for management.

5. Hospital Course
 In the ICU, patient was extubated successfully,
but remained septic and did not return back to
baseline.

6. Advanced Directives
 Social worker was consulted. It was noted
that there was no DPOA or healthcare
directive noted in chart. There was a
POLST form dated 09/03/12, which was
signed by the patient's daughter and
indicated FULL code. It was also noted that
daughter had stated that she had legal DPOA
(unclear if medical or finances); however no
paperwork was provided.

7. Disagreement among Family
Members
 The patient’s son expressed concerns about his sister’s ability to
make sound medical decisions on the patient's behalf.
 He stated that his sister was an Orthodox Jew, and he felt that
she was making medical decisions based on her own personal
religious beliefs and not those of the patient.
 He reported that the patient was a Holocaust survivor and
described her as "culturally Jewish“, but that she did not have
strong religious convictions.
 He believed that his mother should be DNR, and that she should
never had undergone surgery in the first place.

8. Bioethics Consulted
 At this point, bioethics was consulted.
 The goal of a bioethics consultation is to help
those involved reach a moral understanding
that promotes the good of the patient.

9. Bioethics was Consulted
 Bioethical Issue: Surrogacy issue(s): The
patient's daughter has been making decisions and
providing consent. She presents a POLST form,
and states that according to family religion, they
would want maximal treatment including full code.
The patient's son states that medical treatment is
too aggressive and against the patient's values.
The daughter is apparently DPOA but we have no
paperwork to support this claim.
 RECOMMENDATIONS:
I recommended clarification of DPOA and have
daughter bring in appropriate documentation.

10. Tube Feed or Not Tube Feed?
 During the patient’s hospital course, the issue
of artificial feeding came up. The internist
discussed possible PEG placement with
daughter, who was in favor of artificial feeding.
However, the daughter wanted to confer with
her Rabbi first before making a decision.

11. Bioethics Follow Up
 Daughter brought in a DPOA form from 1993,
which identified the patient’s daughter as her
primary surrogate and her son as the alternate
surrogate.
 The document goes on with a statement in the
patient's own writing, reflecting her strong wishes
against resuscitation and prolonged
feedings/hydration in the event of illness from
which she would have no reasonable chance for
recovery.
 She also identifies mental incapacity and coma
as conditions under which she would not choose
to be supported medically.

12. Differences in Opinion Among
Family Members
 However, the daughter continued to state that her
mother would want "everything done“, because
she has always been a survivor. The daughter
continued to reference traditional Jewish religious
philosophy as well as the patient's own
experience as a Holocaust survivor. The
daughter, when asked directly, did admit that her
mother did not practice Orthodox Judaism.
 Furthermore, the daughter expressed hope that
her mother will make a full recovery and get back
to baseline. She also expressed hope that as
soon as tomorrow there would be a cure for
Alzheimer's Disease.

13. Differences in Opinion Among Family
Members
 Meanwhile, the patient's son continued to express that his mother would
not want "everything done“, because she was not an Orthodox Jew and lost
much of her faith as a result of the Holocaust.
 He was concerned that his voice as a surrogate had not been considered in
her care up to this point.
 He was worried that his sister was applying her own principles as an
Orthodox Jew when it came to making health care decisions for their
mother. This included consulting with a Rabbi, and forwarding
documentation from the Rabbi to corroborate her decisions.
 He continued to express that his mother would not have wanted the kind of
surgery she had. Furthermore, she would not have wanted to continue in
her current condition.

14. Bioethics Recommendations
 Recommendations:
 1. Surrogate for this patient - I informed the two surrogates
that despite the DPOA form, it is up to the medical team to
make recommendations and treatment decisions that are
consistent with the patient's values and goals. This may
include choosing the surrogate that best represents the
patient's values and also satisfy the criteria for being an
appropriate surrogate according to hospital policy. I emailed a
copy of our policy to the team physician. More specifically, I
made it clear to the medical team doctor that the patient is
not Orthodox Jew and surrogate decisions for the patient
should be made based on her previously expressed views
and values as clarified through our discussion. This may
involve selecting her son to make surrogate decisions if the
daughter seems to be making decisions contrary to the
patient's values. In such case, Legal may need to be notified
if son is selected as the primary surrogate in conflict with the
patient's Durable POA documentation.

15. Bioethics Recommendations
 2. It is my recommendation that the patient should be
DNR if medically indicated as per her advance directive
(which I placed in the chart). This has already been
ordered by the team physician.
 3. If a gastrostomy feeding tube or prolonged tube
feedings are deemed to have no medical benefit
considering her advanced dementia and deconditioning
they should not be offered by the medical team. The
patient's values in her DPOA form clearly state that
prolonged feeding in a state where there is no
reasonable chance for recovery is not acceptable.

16. Tube Feed or Not Tube Feed?
 Even after the bioethics consultation, the daughter
continued to request PEG tube placement.
 However, the son disagreed with the PEG tube
placement and agreed with the internist’s plan to
have a maximum of 2 weeks trial of tube feeding.
 The internist continued to write in his progress
note:
Daughter, who is current DPOA, does not appear to
be acting in patient's best interest as explicitly
documented in patient's Advanced Directives.
Daughter is current DPOA but son's decisions are
more consistent with patient's expressed wishes.
Will coordinate to have bioethics, IPC involved
again.

17. Bioethics Consult Follow-Up
 The medical team has advised against gastrostomy tube placement
and long term tube feeding in this patient on the basis of non-
beneficial treatment. Additionally, the process of tube feeding would
be against the patient's wishes as dictated in her DPOA
documentation. The patient's daughter (primary DPOA) opposes
this recommendation when approached with the decision today. Her
son (secondary DPOA agrees with the decision).
 Medical decision aside, the patient's daughter is clearly basing her
reasoning on values that are inconsistent with the documentation
and apparent values of the patient before she contracted dementia.
More specifically, the patient outlined that she would not want
prolonged tube feedings if her prognosis was poor ("beyond a
reasonable recovery").
 I have advised the treating physician, if he believes tube feeding is
inconsistent with the patient's beliefs and values and there is no
medical benefit, to initiate the process of invoking the Non-

18. Bioethics Recommendations
1. The medical team should achieve consensus from all
relevant providers that tube feeding is non-beneficial in
this patient. This includes the surgery team and any
other associated consultants.
2. A family meeting should be held to present the
information/decision to the patient's family formally as
well as inform them of process.
3. If there is still a challenge to the medical decision,
then a second opinion not associated with the primary
medical team can provide a second opinion.
4. If the Ethics Review agrees that the process is
appropriately followed and that the treatment is non-
beneficial, the medical team will assist in transfer of the
patient to another facility.

19. Non-Beneficial Treatment Policy

20. Tube Feed or Not Tube Feed?
 As directed by the bioethics recommendation,
the primary internist wrote in his progress note
that he would not recommend long-term tube
feeding and G-tube placement as it would be
non-beneficial treatment as outlined in the
hospital policy on Non-Beneficial Treatment.

21. Second Opinion from Internal Medicine as directed by
Bioethics Recommenation: Tube Feed or Not Tube
Feed?
 I concur that patient clearly expressed in her
written advanced directive that she would NOT
want any long term artificially life sustaining
treatments.
 The current treatment plan for the patient is to
continue temporary NGT feeds and medications
for a defined time trial of 2 weeks in order to
determine if after that time whether or not the
patient would require long term tube feeding to
artificially sustain life.
 In my opinion, the placement of a long term
feeding tube ( PEG ) or ongoing tube feedings (
NGT ) for more than the stated 2 week time trial
would be NON-beneficial to the patient and would
NOT be congruent with the patient's written

22. Third Opinion from General Surgery as
recommended by Bioethics
Recommendation: Tube Feed or Not Tube
Feed?
 Given patient's expressed desires stated in her
Durable Power of Attorney for Healthcare, I feel that
prolonged NG TF and/or the placement of a PEG tube
would be considered non beneficial treatment.
Performance of either would be contradictory to her
expressed desire in her Durable Power of Attorney for
Healthcare document. Doing so would artificially
prolong her life against her stated wishes.
 I agree with the current plan for a temporary trial of 2
weeks use of NG tube feeding for alimentation and
medications.
 In addition I feel that her document further indicates
that she would not want re-operative intervention
should such be necessary.

23. Skilled Nursing Facility
 The patient eventually was discharged to a
skilled nursing facility for rehab.
 During her stay at SNF, the geriatrician abided
by the decision to have two week trial of tube
feeding. He did not change the plan/decision
regardless of the daughter’s insistence.

24. Skilled Nursing Facility
 During the night, the covering physician sent
the patient to the ER as the patient was short
of breath and desatting to the 80s.
 In the ER, she was found to be in sepsis
secondarily to an intra-abdominal abscess
seen on CT.

25. Skilled Nursing Facility
 When the primary geriatrician came in to work
the next day, he found that the patient was
transferred to the ED.
 He held a family meeting and discussed goals
of care and offered home hospice care.
 The daughter did eventually elect for hospice
care.
 The geriatrician spoke with the admitting
physician over the phone, and patient was
sent out on home hospice instead of going
through invasive procedures.

26. Home Hospice Care
 Patient passed away on home hospice three
days later after discharge from ED.

27. Timeline
 Hospitalized from 7/11 – 7/30
 SNF from 7/30 – 8/10
 ED from 8/10 – 8/12
 Home hospice from 8/12 – 8/15
 Passed away 8/15

28. Tube Feed or Not Tube Feed?
 Do you agree with how the situation was
handled?
 Would you have done anything differently?
And if so, what?

29. Tube Feed or Not Tube Feed?
 The American Geriatrics Society does not
recommend percutaneous feeding tubes in
patients with advanced dementia. Instead, it
recommends to offer hand-feeding.
 It has been shown that hand-feeding patients
with severe dementia has the same rate of
death and aspiration pneumonia as patients
who are tube fed.
 Tube-feeding is associated with agitation,
increased use of physical and chemical
restraints, and worsening pressure ulcers.

30. Bioethics Issues of this Case
 Advance directives
 Surrogacy
 Taking off surrogate / Best interest
 Futility / Non-Beneficial Treatment

31. Advanced Directives
 Advance directives (ADs) are the documents a person
completes while still in possession of decisional
capacity about how treatment decisions should be
made on her or his behalf in the event she or he loses
the capacity to make such decisions.
 They are legal tools meant to direct treatment
decision-making and/or appoint surrogate decision
makers.
 The primary instruments that serve as AD documents
are:
1. Durable Power of Attorney for Health Care
2. Living Will (LW)
3. Other documents such as POLST (Physician Orders
for Life Sustaining Treatment)

32. Advanced Directives
 Durable Power of Attorney for Health Care — A
Durable Power of Attorney for Health Care (DPAHC,
Health Care Proxy, or Healthcare Power of Attorney)
is a signed legal document authorizing another person
to make medical decisions on the patient’s behalf in
the event the patient loses decisional capacity
 Living Will — The Living Will (LW) is a document
summarizing a person’s preferences for future
medical care. The typical LW takes effect if the person
is terminally ill without chance of recovery. Typically,
the LW addresses resuscitation and life support;
however, a thorough LW may cover patients’
preferences regarding hospitalization, pain control,
and specific treatments he or she may require in the
future.

33. Advanced Directives
 Physician Orders for Life Sustaining
Treatment — Advanced care planning is most
effective when it is part of a coordinated effort
involving physicians, patients, paramedics,
nursing homes, and emergency rooms. A
model initiative for such a directive is the
Physician Orders for Life Sustaining Treatment
(POLST), which delineates what specific care
should be administered or withheld at the
present time for a specific patient, as directed
by a physician.

34. Surrogacy
 When patients are unable to voice their own
decisions, we look to people in their lives who
can provide guidance based on either their
knowledge of the patient’s wishes (substituted
judgments) or on their understanding of what
is in the patient’s best interest.
 They cannot decide to allow patients to suffer
unnecessary pain when it can be safely
treated.

35. Problems with Surrogates
 If patient’s wishes are unknown to the
surrogate
 If the surrogate lacks decision-making capacity
themselves
 The clinician knows or believes the surrogate
is not acting in accordance with the patient’s
wishes
 The surrogate has difficulty or is unable to
make an informed decision related to the best
interest of the patient
 The surrogate’s decision may be in conflict by
others in the patient’s life (friends or family

36. 3
6
Ethical/ Legal Norms:
Surrogate Decision-Making Standards
Known wishes Substituted
judgment
Best
interests
Known wishes
sometimes require
clarification,
therefore become
“substituted
judgment”
Knowing a
patient does not
always result in
knowing their
preferences

37. What if there’s no assigned
surrogate?
 California law does not provide a hierarchy of
decision makers
 Next of kin is understood as family
 Can also include friends or neighbors
 Law explicitly permits domestic partners
 Physician to identify best decision maker

39. Ethical/ Legal Norms: Decisional Capacity
When Should A Physician Turn to a
Surrogate?
 When patient loses
decisional capacity
 Ability to understand
 Ability to deliberate
based upon values,
beliefs and recognize
consequences
 Ability to communicate
response
What Should We Know about
Decisional Capacity?
 Decision-specific
 Can be intermittent
 Not the same as “legal
incompetence”
 Cognitive impairment does not
= lack of capacity
 Depressed patients do not, by
definition, lack capacity
 Can use consultants (social
worker, psych, ethics)

40. Best Interests
 The surrogate should evaluate treatments by
balancing the benefits and risks and select
those treatments in which the benefits
maximally outweigh the burdens of treatment
 Legally, this standard is considered "objective"
because it does not rely on imagining what the
patient would choose but rather on some
externally defined standard
 Deciding what constitutes a benefit or burden
seems to depend on a patient's personal
values.

41. Futility
 Strict definition: physiologic impossibility of an
intervention achieving its therapeutic objective
 More expanded view may include
interventions that fall below a specific standard
 Example: dialysis filling in for failing kidneys, but
likely won’t contribute to returning the patient to
an acceptable overall health status
 Should not be used to discourage families
from insisting on treatment that care providers
consider inappropriate