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Interpreting a living will after stroke.

D Liao1, M Spremulli, C Wagner

  • 1Harvard Medical School, Boston, Massachusetts, USA.

ASHA
|July 27, 1999
PubMed
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This case study explores the complex ethical decision-making regarding artificial nutrition and hydration for an 83-year-old male with a right thalamic cerebral vascular accident (CVA). It highlights the challenges in discerning patient wishes amidst fluctuating consciousness and advance directive conflicts.

Area of Science:

  • Neurology
  • Geriatrics
  • Bioethics

Background:

  • An 83-year-old male with a right thalamic cerebral vascular accident (CVA) presented with dysphagia, dysarthria, left hemiplegia, and cognitive impairment.
  • Complications arose from a nasogastric feeding tube, leading to nasal tissue necrosis and removal.
  • The patient's advance directive (Living Will) opposed life-sustaining feeding tubes, but a Durable Power of Attorney for Health Care was absent.

Observation:

  • The medical team recommended a gastrostomy tube due to the patient's low alertness and high aspiration risk.
  • Family members were uncertain about the patient's specific wishes regarding artificial nutrition, recalling a comment about a relative's feeding tube prolonging suffering.
  • The patient's alertness fluctuated, impacting his capacity to consistently communicate his preferences.
Keywords:
Death and Euthanasia

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Findings:

  • The patient verbally expressed a willingness to receive "the works" when discussing tube feedings during a period of improved alertness.
  • Despite this statement, his fluctuating consciousness prevented confirmation of his wishes.
  • Daughters advocated for delaying the decision, hoping for improved swallowing function within a week.

Implications:

  • This case underscores the ethical complexities in determining patient autonomy for artificial nutrition and hydration, especially with fluctuating capacity.
  • It highlights the critical need for clear advance care planning and designated healthcare proxies.
  • Navigating conflicting information from advance directives, family interpretations, and patient statements requires careful ethical deliberation and interdisciplinary communication.