AMA Journal of Ethics^®

Case

Mrs. McGoldrick was admitted to the local hospital from a local nursing home with a urinary tract infection (UTI) and multiple chronic diseases including diabetes and a history of heart attacks. Mrs. McGoldrick is 81 years old, has an adult daughter and an elderly sister. During the admission process, Mrs. McGoldrick reported that she could walk only with pain and therefore spent most of her day sitting in a chair. She was evaluated by a psychiatrist immediately after admittance and was prescribed antidepressants to combat symptoms of clinical depression. She was also observed to have indications of early stage dementia.

After spending 3 days in the hospital, Mrs. McGoldrick appeared to have been successfully treated for the UTI but remained weak and lethargic. In an effort to elevate her mood, the anti-depressant dosage was increased, but after several days there were no marked signs of improvement. One of the most distressing trends noted by the clinical staff was Mrs. McGoldrick's intake of foods and liquids. Several tests revealed that she was suffering from hypoprotein anemia which suggested that the she had not been properly nourished for a sustained period of time. The hospital staff, however, observed Mrs. McGoldrick eating and drinking well when her sister fed her during one of her regular visits.

Prior to Mrs. Goldrick's release from the hospital, her primary care physician, Dr. Misenti, spoke privately with Mrs. McGoldricks's daughter, who stated that her mother had expressed a "wish to die," believing that there was nothing more that she wanted from this life. After considering this information, Dr. Misenti suggested continuing the anti-depressants and giving Mrs. Goldrick the option of a percutaneous endoscopic gastrostomy (PEG), which might help raise her mood and nutritional status and, hence, her quality of life. It was Dr. Misenti's hope that by improving the quality of Mrs. McGoldrick's life, he would also encourage her to want to live. Her daughter believed that this was an idea that should be explored and implemented, but Mrs. McGoldrick refused to consider the option.

Commentary 2

In order to justify any medical intervention, eg, placing a feeding tube as in this case, there must be medical indication for the treatment and the consent of the appropriately informed patient.

Medical indication is decisive in determining the clinical foundation for the intervention, ie, whether it should be offered to the patient at all. A physician determines whether a treatment is indicated based on his or her medical knowledge of the course of a disease and the effects of certain interventions on that course. Indication also depends on the physician's knowledge of the diagnosis and prognosis specific to this individual patient and on the aim of treatment. Finally, the physician must consider whether the expected benefit is in due proportion to the harm that may be expected. If a measure has little or no benefit for the patient or if the benefit causes disproportionate risk of harm, the measure has to be considered medically futile and should not be offered to the patient.

The fact that an intervention is medically indicated, however, does not mean that the physician is automatically authorized to carry it out. It is not the physician but rather the patient who decides on the implementation of a measure because patients with decision-making capacity have the right to self-determination. If a patient refuses or withdraws consent after learning about both the benefits and the risks, treatment is not justifiable. The prerequisites for providing informed consent are decision-making capacity and appropriate patient information. If the patient does not have decision-making capacity, the physician should ask whether he has given his opinion on the situation at an earlier date when he was determined to be of adequately sound mind, perhaps in the form of a living will. If this is not the case, the patient's interests must be represented by a proxy or "surrogate" decision maker or, if this is an emergency situation, by the physician himself.

Application to the Present Case

The first question the physician should ask himself is whether Mrs. McGoldrick presently has decision-making capacity. If she does, he should offer her the opportunity to reconsider her decision against a PEG; coercion and, especially, treatment of the patient against her will would interfere with her right to self-determination and would therefore be ethically unacceptable. Whether Mrs. McGoldrick has decision-making capacity cannot be answered definitively based on the information presented in this case. Her age, treatment with antidepressants, and early stage of dementia do not exclude decision-making capacity but do require the medical staff to be aware of possible compromised decision making. The determination of her competence must also consider whether she is presently capable of understanding the consequences of her refusal for additional treatment. To decide this, it might be helpful to investigate whether the refusal of the treatment is authentic— in other words, consistent with her other known values and goals. If the physician has any doubts regarding Mrs. McGoldrick's decision-making capacity, he should consult a psychiatrist.

The aim of the proposed procedure is to raise the patient's mood and nutritional status and hence, her quality of life. Yet it is questionable whether a PEG is a suitable means to this end. The fact that Mrs. McGoldrick eats and drinks sufficiently when fed by her sister suggests that her insufficient nutritional status has a social and caregiving explanation rather than a medical basis. The staff at the local nursing home probably does not have enough time to feed Mrs. McGoldrick, and this further perpetuates her social isolation. Maybe the food is not presented in an appealing way (eg, big portions) or Mrs. McGoldrick finds this previously shared time very lonely. Instead of considering PEG, those in charge should first try to improve the social situation and nursing care of Mrs. McGoldrick through greater involvement of her older sister and her daughter.

The other rationale offered for inserting the PEG is that artificial feeding would counteract imminent malnutrition and thus contribute to life extension. Without improving the social and caregiving situation, this seems to be a futile goal, since Mrs. McGoldrick has made it clear—explicitly to her daughter and implicitly by refusing to eat and drink—that she does not want to live that way.

Conclusion

Application of PEG in this case seems to be neither medically reasonable nor in the patient's best interest. PEG is not an appropriate means for solving social or caregiving deficits. Should it not be possible to improve Mrs. McGoldrick's quality of life by social and caregiving measures, it seems to make little sense to extend the situation artificially by PEG since the patient herself obviously does not wish for this lifestyle. Apart from the questionable medical indication, Mrs. McGoldrick's refusal to even discuss the possibility of PEG clearly speaks against taking this measure. If Mrs. McGoldrick is still able to grasp the consequences of her decision, and is determined to have decision-making capability, her refusal is binding for the physician. If she is deemed to lack decision-making capacity, her refusal would at least be an important indicator that PEG was not her preference, which is supported by her refusal to eat and her earlier statements to her daughter, and should be taken into account by surrogates and physicians when making treatment decisions.