M.L. was a 76-year-old female patient with history of COPD, atrial fibrillation, congestive heart failure, hypertension and type 2 diabetes. She was admitted to St. Bridget's Hospital after suffering a stroke that left her paralyzed on one side, unable to speak or swallow and without capacity. She could open her eyes, but it was unclear as to the degree of awareness she had of her surroundings. She did not indicate that she recognized her family. Mrs. L. was widowed and lived with a daughter. Prior to the stroke, she had been able-bodied. She no longer drove or prepared meals but was able to perform self-care. She could feed herself and could navigate within her daughter's home independently.
Mrs. L's daughter was overwhelmed by the degree of her mother's impairment from the stroke. She knew she could no longer care for her, especially now that she was bedridden. In discussing nutritional support, Mrs. L's daughter declined a feeding tube. She did not think her mother would survive long-term and did not want to add to her mother's burden. Mrs. L's physician was unsure of how to proceed because she did not feel the stroke was necessarily terminal. The palliative care team was consulted to assist with the ethical and legal guidelines regarding artificial nutrition and hydration, specifically in someone without capacity and without an advance directive.
Mrs. L's vital signs were stable. Her blood pressure would trend upward at times but was controlled with medication. Her lab values were essentially normal. She failed a swallowing study that resulted in a recommendation to not take anything by mouth. The stroke team had weighed in with a guarded prognosis for recovery. There was no documentation stating the opinion that Mrs. L was going to die from this stroke. The attending physician was asked for her opinion regarding whether Mrs. L would die first from her medical condition or from the lack of food and water if she was not given nutrition and/or hydration.
The physician's opinion was that the patient would die first from lack of nutrition and hydration. Based on this assessment, the indication was to proceed with trial feedings through the use of a nasogastric feeding tube. If tolerated, Mrs. L would then be evaluated for placement of a more permanent gastric feeding tube.
This discussion was brought to Mrs. L's family and the daughter she lived with. They voiced their understanding and support to go forward with attempting to feed. A Dobhoff feeding tube was placed and tube feedings were started.
Within 24 hours Mrs. L showed new signs of having extended her stroke. She was no longer able to open her eyes. Her breathing was affected and she had less control of her oral secretions. It was thought that she had aspirated and was showing significant deterioration. Assessment for the more permanent feeding tube was placed on hold and the palliative care physician suggested observing Mrs. L for the next 24 to 48 hours.
Within two days Mrs. L was thought to be imminently dying. She was unresponsive and with worsening respiratory status. She was congested and breathing with some difficulty. The family was updated by both the primary and palliative care physicians. Direction of care became solely that of comfort.
Because it was thought that Mrs. L was now imminently dying and because her stroke had further impaired her ability to protect her airway, tube feedings were stopped and the nasogastric feeding tube was removed. Medicines were provided in low doses to calm her breathing and reduce the amount of excessive secretions. A lubricating solution and ointment were kept at the bedside to keep her mouth and lips moist. A private room was provided where family could be present. About 36 hours later Mrs. L died with symptoms controlled and in what appeared to be a peaceful manner. (Courtesy of St. John Medical Center, Tulsa, OK).