Artificial Nutritional Support: The Daughters’ Dilemma

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Mrs. W is a 73-year-old woman with a history of type II diabetes mellitus and coronary artery disease. She has been at an acute rehabilitation hospital for 10 days after the onset of a left thalamic hemorrhage with resultant aphasia, confusion, right hemiplegia, right neglect, and severe dysphagia. She had been living at home with her husband who has been diagnosed with moderate dementia. Mrs. W has been his primary caregiver. Since admission, the patient has been consistently somnolent. She had a nasogastric (NG) tube placed in the acute care facility to sustain her nutrition and hydration secondary to severe dysphagia. The patient’s right nares had become very swollen and irritated, and the tube was removed and replaced in her left nares. The patient pulled the NG tube out during the following night. Mrs W’s left nares were then similarly swollen, and it would be difficult or impossible to place another tube down that side. The patient does not have a formal advance directive. Her two daughters (her only children) have been serving as her proxy decision-makers. They have been asked to provide consent to allow Mrs. W to have a percutaneous gastrostomy (PEG) tube placed to sustain nutrition and hydration. The patient’s speech-language pathologist does not recommend a videofluoroscopic swallow evaluation at this time, because the patient is not even able to recognize that she has food in her mouth during a clinical examination. The daughters indicate that this is a very difficult decision for them to make. They report that in past conversations, their mother stated that she would not want to live with a feeding tube. These discussions had been prompted by the illness of Mrs. W’s sister, who recently died after a battle with esophageal cancer. Mrs. W’s sister had