Martha, an 83-year-old retired school teacher, was admitted to Oakridge Skilled Nursing Facility two years ago. At that time, she appeared to have altered mental status and questionable deci
Case Analysis Description
Martha, an 83-year-old retired school teacher, was admitted to Oakridge Skilled Nursing Facility two years ago. At that time, she appeared to have altered mental status and questionable decisional capacity, however, she was not formally declared incompetent by a court until six months ago due to declining cognitive status. Upon arrival at the skilled nursing facility, Martha’s son, Jeff, provided her past medical records and advance directive (living will). The directive indicated that Martha had initialed “no surgery, heart-lung resuscitation, dialysis, antibiotics, mechanical ventilator, or tube feeding.” Together Jeff and the admitting nurse read through it while Martha sat beside them, apparently not comprehending everything they were discussing. Jeff, who had been his mother’s primary caregiver for years prior to her move into Oakridge, signed all intake paperwork feeling confident that this was the right decision for his mother and his family. From that time on he visited his mother frequently and was always cooperative when the nursing center requested information or guidance.
As years have passed, Martha has begun eating less and taking significantly more time to consume the little amount that she does eat. She is no longer able to feed herself and requires 2-3 hours of assistance from a nursing aide to feed her each meal. The nursing director mentioned to Jeff that consideration should be given to the insertion of a feeding tube for his mother. Martha is not acutely ill; clearly she is an elderly woman with multiple disabilities, but she is not in danger of imminent death. All she needs is sufficient nutrition, yet the nursing director feels she cannot justify an aide’s time being devoted to one patient for so long of a period three times a day. Jeff initially feels betrayed when this is suggested- he admitted his mother to a nursing facility to ensure her basic needs were met, yet adequate nutrition seems very basic and may not be met without the feeding tube. He did not foresee that his mother’s advance directive might mean she will starve to death. This, added to his grief over his mother’s declining health, has created an enormous emotional burden for Jeff. Conversely, the nursing facility must ensure that their limited resources are allocated fairly amongst all patients. Martha’s needs have begun to require more care than the nursing facility can provide without neglecting other patients.
Jeff knows that his mother’s advance directive was made one day when a friend was visiting, and all that she told him about it was that she didn’t want to be “kept alive on a machine.” When Jeff and the nursing director are talking, Jeff says he does not consider tube feeding a “machine” and his mother most likely did not understand the implications of her initialed statement, ”No Tube Feeding.” After much consideration, Jeff agrees with the nursing director that it would be better for Martha if a tube is inserted.
When the Oakridge Skilled Nursing Facility administrator was informed of the decision to place a feeding tube, she felt uneasy because tube feeding would prolong Martha’s dying, and explicitly went against the patient’s written advance directive. Alternatively, she also recognized that by not administering the feeding tube other patient’s needs may be neglected, and Martha may not receive adequate nutrition- a scenario she doubts Martha considered when writing her advance directive. The administrator calls a meeting with an ethics committee, Martha’s medical team, social work, and Jeff to discuss this matter.
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