Case Study 1: Withdrawing Nasogastric Feeding

Mdm Lee left China at the age of 16 to escape an arranged marriage. Her second job in Singapore was as an ‘amah’ (nanny) for a Chinese-speaking family. She has been part of the family ever since, caring for three generations of children for over 45 years, and continuing to live with the family following her retirement.

Mdm Lee is now 90 years old. Four years ago, after a series of falls greatly impaired her mobility, she was admitted to a nursing home. At the time of her admission to the nursing home, she was suffering from several chronic conditions, including diabetes, but was cognitively intact. Since that time, Mdm Lee has been diagnosed with Alzheimer’s disease which has resulted in progressive cognitive impairment. Her care is arranged and paid for by two members of the family for which she worked: Mr Heng, and his aunt, Mrs Yong, who is Mdm Lee’s surrogate decision-maker now that Mdm Lee no longer has the capacity to make medical decisions for herself. Mr Heng, Mrs Yong, and other members of the family take turns visiting Mdm Lee each week. While she is no longer able to recognise them, she always seems happy to see them.

The nursing home offers advance care planning (ACP) to its residents, so that all nursing home staff and others involved in a resident’s healthcare have documentation of a resident’s wishes for future medical care. Two years ago, while she was still cognitively intact, Mdm Lee documented her advance wishes with the help of a senior nurse. Mr Heng and Mrs Yong also took part in this meeting, translating the senior nurse’s instructions and questions into Mdm Lee’s native Fujian dialect, and translating her responses for the nurse to document.

Mdm Lee had always been afraid of hospitals and invasive medical procedures. As she would often say, ‘I don’t like having things stuck in me.’ During the ACP discussion, Mdm Lee chose not to be hospitalised, resuscitated, or tube fed should her condition deteriorate seriously and irreversibly. She gave consent to receive certain medical treatments, such as antibiotics and her diabetes control regimen, within the nursing home. She also authorised Mrs Yong to make medical decisions for her should she become unable to do so, saying, ‘I have known her since she was a baby – she will know the right thing to do.’

In recent weeks, Mdm Lee has been losing her ability to swallow. This is a symptom of advanced Alzheimer’s disease, which itself is an irreversibly progressive and ultimately a terminal condition. Nursing home staff became frustrated when attempts to feed her the nightly meal induced episodes of choking. Several members of staff told a senior nurse, Ms Judy Ang, ‘We’re trying to follow her diabetes care plan, but we can’t get the food and medicine into her.’

After several days of these problems, Nurse Ang inserted a nasogastric (NG) feeding tube, telling the other staff present, ‘We don’t want someone to complain that the patient had nothing to eat or drink and didn’t get her medicines. Let’s see if this works.’

Mdm Lee appeared to find the NG tube uncomfortable. She tugged at it and eventually pulled it out. When Nurse Ang replaced the NG tube, the staff placed mittens over Mdm Lee’s hands to prevent her from pulling out the tube again. The NG tube and restraints caused Mdm Lee to become agitated. Nurse Ang contacted the nursing home’s medical director, who ordered a mild sedative for Mdm Lee.

When Mr Heng and Mrs Yong arrive that weekend for a visit with Mdm Lee, Mr Heng is horrified to see a sedated Mdm Lee with an NG tube and restraints. He tells the senior nurse on duty, ‘She said no to the NG tube and you forced her to have it. I helped her with that form, so I am responsible for having her wishes carried out, aren’t I? What on earth is the point of making an advance care plan if you don’t respect her wishes?’

Case Study Prompts;

What are the ethical issues in this scenario?

How could the ‘Ethical Principles’ be used to guide the nurse in what to do?

Is Mdm Lee able to make legal decisions?

What is Advanced Care Planning (ACP)?

Should the nurse have inserted a Nasogastric Tube?

What legal documents are relevant here to help the nurse?

Are there any Principles in the SNB ‘Code for Nurses and Midwives (2018)’ that could help guide the nurses’ decisions?

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