Ethical Considerations



Ethical Considerations


MICHAEL E. GROHER



CHAPTER OBJECTIVES



1. Present the basic principles of medical ethics as they relate to the swallowing-impaired patient.


2. Discuss the risks and benefits of alternative types of feeding.


3. Highlight the differences between factors that predict aspiration and those that predict aspiration pneumonia.


4. Present an approach for weaning from feeding tubes.


5. Present examples of ethical dilemmas resulting from the placement or retention of alternative forms of feeding.



MEDICAL ETHICS


The Patient Self-Determination Act took effect on December 1, 1991. The act established guidelines to allow patients to participate fully in decisions regarding their health care, particularly decisions made in circumstances of severe or terminal illness. The act strives to establish a patient-physician interaction that allows both parties to balance individual morals and values against the known risks and benefits of proposed medical care. For example, patients might want to decide under which circumstances they would want to be resuscitated or whether they would want to be nourished by a feeding tube to sustain life. Counseling patients, families, and caregivers on the risks and benefits of tube feeding may involve the expertise of the dysphagia specialist.1 One study found that speech-language pathologists (SLPs) who manage patients with dementia are involved in the decision making in 65% of cases when the recommendation is made for some type of alternative nutrition.2


Medical ethics is a subspecialty of medical care that brings together patients, caregivers, and nonmedical and medical professionals in an effort to make the best decision regarding a health care issue. The decision rests on the understanding that it is finalized by balancing data from individual and societal morals and values, evidence-based medical knowledge, and legal precedent. Ethical dilemmas result when balance is not achieved—when one party is not in agreement with the plan of care. For example, a patient may not agree to the short-term use of a nasogastric feeding tube (NGT) because of religious objections, although the medical team is convinced that it may save or prolong the patient’s life. These dilemmas need to be resolved and may be referred to the medical center’s ethics committee. Solutions generally are possible with a rational analysis of (1) how the patient came to establish his or her health care preferences; (2) the medical risks and benefits of a proposed intervention; (3) the burdens that medical intervention might bear on the patient and family; (4) the effect on the patient’s and family’s quality of life; and (5) any legal constraints, such as the patient being incapable of making an informed decision.



Advance Directives


The advance directive (AD) is a statement made by a person with decision-making capacity indicating his or her preferences for receiving medical treatment or not receiving medical treatment under certain circumstances. When a person is admitted to a medical setting, the patient is automatically given the option to execute an AD. Admission is not contingent on signing an AD, and patients frequently do not. Any member of the health care team may initiate the document if he or she thinks it will facilitate the patient’s care. If an AD has already been executed, either from another admission or as a document the patient executed in the past, it will be placed prominently in the medical record so the medical team can be guided by the patient’s wishes in the event of a medical crisis. Most often an AD is specific to end-of-life decisions or circumstances when an individual’s medical condition is futile. Typically, the AD has two parts: a living will and a durable power of attorney for health care. The living will is a written request to forego some type of medical treatment in a terminal or irreversible medical condition. The durable power of attorney for health care appoints a person (surrogate) to act in the patient’s behalf on end-of-life or irreversible conditions should the patient be in a state that he or she is not competent to make an informed decision. It is understood that the surrogate will have prior knowledge of the patient’s desires and therefore will act in the patient’s best interest. Patients with terminal, progressive diseases should be encouraged to execute an AD while they are competent and free from severe disease to facilitate end-stage medical care. Making decisions about tube feeding when the patient is in a crisis often clouds a rational decision and may complicate medical care.



CLINICAL CORNER 15-1


A patient’s surrogate told the medical care team that she wants to discontinue her husband’s oral feeding because she has noticed as she assists him at mealtime that he has considerable choking episodes. Based on the patient’s clinical and instrumental swallowing evaluations, the treatment team believes that he should be able to continue eating orally.




CLINICAL CORNER 15-2


A 58-year-old man has a 3-year history of amyotropic lateral sclerosis. A swallowing study has shown that he aspirates with a weak cough on all consistencies. Although the patient does not have an advanced directive, he is adamant that he wants to continue eating orally.




TUBE FEEDING


Because most ethical dilemmas that the swallowing specialist faces center on the use or denial of tube feeding, it is important to understand the risks and benefits of this intervention. Tube feeding entails psychological and medical risks and benefits.


There are two major categories of nonoral nutritional provision: enteral and parenteral. Nonoral parenteral feedings are sometimes collectively referred to as hyperalimentation.



Enteral Nutrition


The major types of enteral tube feeding include nasogastric, gastrostomy, and jejunostomy. Specially prepared high-calorie formulas are delivered through the tube into the feeding site. They are delivered from a syringe, a plastic bag that hangs above the level of the tube site, or a mechanical pump.



Nasogastric Tubes


Tubes that are inserted through the nose and into the stomach can be used to deliver nutrients or suction unwanted secretions. Tubes that provide nutrition are nasogastric feeding tubes. They range in diameter from 8 to 18 Fr. Usually the larger the diameter (18 Fr), the stiffer and more uncomfortable the tube is in the nose and throat. Larger nasogastric feeding tubes are necessary for passing medications and pureed foods. They do not clog as much with these materials as do smaller bore tubes. Smaller bore tubes take thin liquid formulas, sometimes are prone to clogging and dislodgment, and generally are more comfortable in the aerodigestive tract. Smaller bore tubes that are weighted on the tip for ease of passage are called Dobhoff tubes.


The nasogastric feeding tube is inserted through the nostril into the pharynx, through the pharyngoesophageal segment into the esophagus, and finally through the lower esophageal segment into the stomach. In some cases it is passed beyond the stomach, through the pyloric valve, and into the jejunum. A special radiograph (kidney-ureter-bladder) is ordered to ensure that the tube is positioned correctly in the aerodigestive tract before feeding begins. NGTs are used in acute medical situations that render the individual unable to swallow or to sustain nutrition orally. A nasogastric feeding tube is used when the medical care team believes that the patient’s medical status has a good chance to improve in a short period. Although the length of time for use of an NGT is not prescribed, if a patient requires enteral feeding for longer than 3 or 4 weeks another enteral feeding method usually is selected. More permanent options that are still reversible include gastrostomy or jejunostomy feeding tubes. These tubes can be placed surgically (usually requiring general anesthesia for the patient) or endoscopically (requiring light anesthesia). Endoscopic placements are called percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ).



Gastrostomy and Jejunostomy Tubes


The gastrostomy tube is placed directly into the stomach with the assumption that the digestive processes of the stomach are intact. Formula is passed through a catheter that sits on the outside of the stomach. If the stomach is not functioning, the feeding tube may need to be placed into the jejunum of the small intestine. Because the stomach is bypassed, specialized, predigested formulas are required for jejunal tube feedings. Some clinicians argue that jejunal placement reduces the risk of reflux of the tube-fed material into the pharynx because the pyloric valve provides an additional barrier to retropulsion of stomach contents into the esophagus. However, the experimental evidence does not clearly support this contention.3 Table 15-1 summarizes the medical risks and benefits of enteral tube feeding.




Parenteral Nutrition


Parenteral nutrition is indicated when the gastrointestinal tract cannot be used because of medical complications such as gastroparesis, obstruction, or bleeding. Total parenteral nutrition (TPN) is a specialized formula that most commonly is delivered into a central vein (subclavian or internal jugular). Although there are potential medical complications from this therapy, such as pneumothorax, patients can be supported nutritionally with this formula for 4 to 6 weeks if necessary.4 Peripheral parenteral nutrition (PPN) is a form of nutritional support delivered through a peripheral vein. Because of potential medical complications, this therapy can be used effectively for only 7 to 10 days.4 Intravenous feeding is a common form of parenteral nutrition, usually providing hydration and medication only rather than more complex elements such as amino acids. Hypodermal clysis is a form of parenteral nutrition that is given for hydration through the subcutaneous tissues in the chest, thigh, or abdomen. Table 15-2 summarizes parenteral and enteral alternative nutrition and hydration.



TABLE 15-2


Summary of Potential Methods of Providing Nutrition















































Type of Nutrition Delivery Route of Delivery Method of Delivery Indications for Use Types of Formula Possible Complications
Simple IV/CTPN IV (small vein; catheter inserted or surgically placed for CTPN in deep central vein) Continuous or cyclic infusion by pump Supplemental hydration; restoration of fluid and electrolyte balance, need for complete parenteral nutrition or long-term CTPN

Nasogastric tube Catheter/tube placed transnasally to the stomach Intermittent or continuous drip by pump Short-term alternative to oral intake (approximately 2 weeks); transnasal insertion, easily removed Commercial nutritionally complete (standard, hydrolyzed, modular) supplements; regular liquids Misplacement into the airway; irritation to nasal, pharyngeal, esophageal mucosa; discomfort; negative cosmesis; may affect swallow function; may contribute to reflux and aspiration
G-tube/PEG Feeding tube inserted directly into the stomach Bolus or gravity (syringe); drip by infusion pump Option for long-term alternative to oral intake; does not necessarily preclude oral intake in certain cases Commercially prepared nutritionally complete enteral formulas; fiber supplements, supplemental and regular liquids, select medications; some individuals may liquefy table foods Nausea, vomiting, diarrhea, constipation, reflux, clogged tube, skin irritation at gastrostomy site; aspiration
J-tube/PEG Feeding tube inserted directly into the jejunum (small intestine) Bolus or gravity syringe; drip by infusion pump Does not require stomach for digestion; allows enteral nutrition earlier after stress or trauma; less risk of reflux and aspiration Commercial prepared nutritionally complete enteral formulas; fiber supplements, supplemental liquids Loss of controlled emptying of the stomach; misplacement; diarrhea, dehydration
Hypodermal clysis Subcutaneous; common infusion sites are the chest, abdomen, thighs, and upper arms Injection (3 L in 24 hours/two sites) Hydration supplement for mild to moderate dehydration Saline; half saline/glucose; potassium chloride can be added Mild subcutaneous edema

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Aug 27, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Ethical Considerations

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