[Dysphagia] Ethical Issues Update

[Paula.Leslie at newcastle.ac.uk (Paula leslie)]

Hello All

Many moons ago (see end of post) we asked for thoughts on an ethical case and 
I thought you all might like an update.  Please don't let this send your blood 
pressure through the roof... my colleagues have been put back on the reserves 
bench and are a somewhat surprised by the events!

Thank you again to all those who offered their wisdom.

Paula



"All took a very unexpected turn. At last joint meeting we had (C, wife, GP, 
NH matron and ourselves) wife raised query re: C's capacity to make decisions. 
This was a surprise to the rest of us, but on further discussion after the 
meeting, she indicated that she would like him assessed to clarify. A 
psychiatrist visited C and decided he was suicidally depressed. Recommended 
ECT; C not in a position to make decisions.

I did feel uneasy that an individual could assess C in total isolation from 
the rest of the team, with no discussion at all, and make such a radical 
change. Anyway, it means that the situation is out of our hands at present. 
The current recommendation (from psychiatrist) is that C has individual 
attention at mealtimes to assist mood. GP has chosen medication route rather 
than ECT. We are awaiting further contact once C is through this period of 
treatment.

So all very unexpected and not what we were hoping for."



>-----Original Message-----
>From: dysphagia-bounces@b9.com [dysphagia-bounces@b9.com] On
>Behalf Of Paula leslie
>Sent: Wednesday, December 07, 2005 1:57 AM
>To: Dysphagia List
>Subject: [Dysphagia] Ethical Issues
>
>Hello All
>
>I received this request to post. I work with this team and have been
>involved with the person concerned in the past. It's a complicated issue but
>communication has been open and frank since the start. C's wishes have
>always been addressed. (GP = US family practitioner, C lives in the US
>equivalent of an SNF).
>
>As ever any input would be very welcome!
>
>Thank you
>
>Paula
>
>
>
>We are seeing a 64 year old man (C) with Parkinson's disease. He is
>currently wheelchair-bound and uses a lightwriter to communicate. He is
>physically unable to feed himself.
>He has had gradually increasing difficulties with eating and drinking
>over the past 3 years and had a PEG fitted in December 2004. Since that
>time, he has had 3 phases of trying small amounts of oral intake. On each
>occasion, oral intake was stopped after a few weeks due to chest infection
>problems.

>Once chest status improved, the small amounts of intake have recommenced. On
>the 3rd occasion (August 05), the client developed a chest infection after
>12 days of having small amounts of oral intake. NBM status was implemented
>and he has not resumed oral intake since. One occasion of chest infection
>required hospital admission.
>
>We had a meeting with nursing home staff, the client and the client's
>wife to clarify issues.
>Nursing home staff are concerned at putting C at risk by offering any
>oral intake. They are concerned that his chest problems develop very quickly
>and that he can be distressed and with breathing problems within half an
>hour of the problems starting to show.
>C is very anxious to eat and feels that staff are being over -cautious.
>
>We agreed to arrange a Videofluoroscopy assessment of C's swallow to
>clarify the nature of his swallowing difficulties. This showed that honey
>and pudding consistencies were swallowed without aspiration occurring but
>that liquid barium was aspirated silently. It was also not possible for C to
>cough to request to clear his throat.
>
>We have had a meeting with C, his wife, nursing home staff, GP and
>ourselves to discuss the situation. The issues were:
>SLTs think small amount of suitably textured input may be possible with
>very rigorous oral hygiene to reduce risk of oral secretions mixing with
>oral residues and being subsequently aspirated. Also recognise that C
>looking physically better since being NBM and that incidence of chest
>infections has reduced whilst NBM.
>C - very anxious to have some oral intake. Aware of risks.
>C's wife - does not want him to have oral intake as she thinks C is
>much fitter since oral intake stopped and she is concerned with how poorly
>he is when chest infections occur.
>GP - concerned by serious chest infections that have made C very ill.
>Also very keen to recognise C's wishes.
>Nurses - very reluctant to feed C because of risk to him and not wanting
>to make him ill.
>
>Conclusion
>
>Difficult ethical situation. All involved professionals seeking advice
>from colleagues and professional bodies before follow - up meeting in 2
>weeks.

Paula Leslie
Degree Programme Director

Surgical and Reproductive Sciences
Faculty of Medical Sciences
University of Newcastle
Newcastle upon Tyne
NE2 4HH
UK
+44 (0) 191 222 6279(T)/8988(F)
http://www.ncl.ac.uk/sars/postgrad/MSc.htm