Ethics in Medicine
- -Patient Self-Determination Act of 1991
1. Set guidelines to allow patients to participate fully in ____.
2. Important in ______ - -When parties disagree, solutions based upon:
1. How patient established preference
2. ___________
3. ____ on patient and family
4. Effects of patient and family _____
5. _____ constraints
- -Patient Self-Determination Act of 1991
1. Set guidelines to allow patients to participate fully in decisions regarding their health care.
2. Important in severe or terminal illness situations - -When parties disagree, solutions based upon:
1. How patient established preference
2. Medical risks and benefits
3. Burden on patient and family
4. Effects of patient and family QOL
5. Legal constraints
Advanced Directives
- -Statement made by a person with ______ indicating his/her ___ for ____ under certain circumstances (Groher & Crary, pg. 309)
- -Two parts:
1. Living Will-written request to ________
2. Durable Power of Attorney- appoints a ___ to act on patient’s behalf in case of _______ - -Natural death choices
1. Not currently in place in the ____
2. Other countries: Australia, Natural Death Act of South Australia of 1983
- -Statement made by a person with decision-making capability indicating his/her preferences for treatment under certain circumstances (Groher & Crary, pg. 309)
- -Two parts:
1. Living Will-written request to forego some type of treatment
2. Durable Power of Attorney- appoints a surrogate to act on patient’s behalf in case of end-of-life or irreversible conditions - -Natural death choices
1. Not currently in place in the USA
2. Other countries: Australia, Natural Death Act of South Australia of 1983
Causes of Ethical Dilemmas
- -Patient of caregiver does not ___ or fails to _____
- -Best course of care may not be __ or _______
- -Medical team and patient have __ ___ interfering with rational decision-making
- -Not clear if surrogate is acting in ___ or _____
- -Not clear what patient or surrogate desires as an ____
–NOTE: “SLP should never be in a position to decide to stop alternative feeding for clients. A __ ___ or family undertake to analyze the ethical dimensions, provide alternative options and predict consequences.” (Serradura-Russell, 1992)
- -Patient of caregiver does not agree or fails to understand medial team’s plan
- -Best course of care may not be clear or multiple opinions exist
- -Medical team and patient have personal biases interfering with rational decision-making
- -Not clear if surrogate is acting in patient’s behalf and in his/her best interest?
- -Not clear what patient or surrogate desires as an outcome
–NOTE: “SLP should never be in a position to decide to stop alternative feeding for clients. A medical team or family undertake to analyze the ethical dimensions, provide alternative options and predict consequences.” (Serradura-Russell, 1992)
Transition from oral to tube feeding: Choices Available
- -No intervention:
1. Continue ______
2. ___ devices (suctioning) and ___ measures (pain relief) provided - -Modifications:
1. Attempts combinations of ______
2. ___ and family education - -Alternative/Tube feedings
1. Could receive required ___ & ___
2. Oral feeding for ____ only
- -No intervention:
1. Continue eating and drinking orally
2. Assistive devices (suctioning) and comfort measures (pain relief) provided - -Modifications:
1. Attempts combinations of oral and tube feeding
2. Counseling and family education - -Alternative/Tube feedings
1. Could receive required nutrition and hydration
2. Oral feeding for pleasure only
Tube Feeding
- -__and__ risks and benefits
- -Review: Feeding Tubes
- -Two major categories of tubes: Hold on–Next slide!
1. ___
2. ____ - -Reasons to tube feed
1. Can’t sustain __ ___
2. Need __ ___ short-term
3. Risk of ____
- -Psychological and medical risks and benefits
- -Review: Feeding Tubes
- -Two major categories of tubes: Hold on–Next slide!
1. Enteral
2. Perenteral - -Reasons to tube feed
1. Can’t sustain oral nutrition
2. Need more calories short-term
3. Risk of aspiration
Feeding Tubes Revisited(Tables 15-1/15-2 in Text)
- -Enteral
1. ___ tube - uncommon
2. ___Tubes-less than 3-4 weeks
3. ___ Tube (G-tube)/ ___ ___ __ (PEG)
4. ___ (J-Tube)/Percutaneous Endscopic Jejunostomy (PEJ) - -Parenteral
1. ___ __ __ (TPN)- central vein-subclavian or jugular- 4-6 weeks only
2. __ ___ __ (PPN)-through a peripheral vein- 7-10 days
3. ___ feeding
4. __ ___-hydration through subcutaneous tissue
- -Enteral
1. Orogastric tube - uncommon
2. Nasaogastric Tubes-less that 3-4 weeks
3. Gastrostomy Tube (G-tube)/ Percutaneous Endoscopic Gastrostomy (PEG)
4. Jejunostomy (J-Tube)/Percutaneous Endscopic Jejunostomy (PEJ) - -Parenteral
1. Total Parenteral Nutricion (TPN)- central vein-subclavian or jugular- 4-6 weeks only
2. Peripheral Parenteral Nutrision (PPN)-through a peripheral vein- 7-10 days
3. Intervenous feeding
4. Hypodermal clysis-hydration through subcutaneous tissue
Review: Aspiration Pneumonia
- -Lung infection the results from 3 primary sources:
1. Aspiration during a ___ including ___
2. __ of swallowed contents that are eventually aspirated
3. Aspiration of ___contents - -Signs:
1. Shortness of ___
2. Rapid __ ___
3. Acute __ -__
4. ___
5. Elevated ____ within an hour of eating
- -Lung infection the results from 3 primary sources:
1. Aspiration during a swallow including saliva
2. Retention of swallowed contents that are eventually aspirated
3. Aspiration of gastro-esophageal contents - -Signs:
1. Shortness of breath
2. Rapid hart rate
3. Acute mental confusion
4. Infection
5. Elevated temperature within an hour of eating
Who gets Aspiration Pneumonia?
- -Not all who aspirate get __ ___!
- -Factors are unknown: Helps to have____
1. Aggressive __ ___ (Langmore, 98)
2. Strong ___
3. Strong ___ system - -How much and what types of materials cause aspiration pneumonia?
- -Not all who aspirate get aspiration pneumonia!
- -Factors are unknown: Helps to have____
1. Aggressive oral care (Langmore, 1998)
2. Strong cough
3. Strong immune system - -How much and what types of materials cause aspiration pneumonia?
Factors that increase risk of developing aspiration pneumonia:
- __ __ __/COPD
- Multiple ___ (sedatives)
- Feeding ____
- Poor __ ___
- ___
- Prior history of __ ___
- Neck ____ while eating
- Use of ___
- ___ state
- Having a __ ___ in place
- Congestive Heart Failure/COPD
- Multiple medications (sedatives)
- Feeding dependence
- Poor oral hygiene
- Smoking
- Prior history of aspiration pneumonia
- Neck hyperextension while eating
- Use of suctioning
- Bedbound state
- Having a feeding tube in place
Tube Feeding and Aspiration
–Common dilemma: patient aspirates does not want __ ___
- -Literature suggests:
- > Terminal/ critically ill patients-
1. Tube feeding does NOT reduce incidence of ____
2. Does not __ ___ beyond expected limits - > Dementia or longer life expectancy-
1. May extend life without undo ___
2. Not interested in ___? Force Feeding?
–Common dilemma: patient aspirates does not want feeding tube
- -Literature suggests:
- > Terminal/ critically ill patients-
1. Tube feeding does NOT reduce incidence of aspiration
2. Does not prolong life beyond expected limits - > Dementia or longer life expectancy-
1. May extend life without undo risk
2. No interested in eating? Force Feeding?
Clinical Corner (Crary & Groher, pg. 313)
The dysphagia team is in total agreement that a gastrostomy tube should be placed in a mentally incompetent post-stroke patient who is 89 years old. The family member who is the legal surrogate is against placement and asks that his mother be fed despite the risks. Some of the nursing assistants who were helping feed her have refused because they believe they are hastening her death. The family member has threatened to sue the hospital for negligence because it is his perception that his mother is not receiving good care and that the team is “against him” for not taking their advice.
The dysphagia team is in total agreement that a gastrostomy tube should be placed in a mentally incompetent post-stroke patient who is 89 years old. The family member who is the legal surrogate is against placement and asks that his mother be fed despite the risks. Some of the nursing assistants who were helping feed her have refused because they believe they are hastening her death. The family member has threatened to sue the hospital for negligence because it is his perception that his mother is not receiving good care and that the team is “against him” for not taking their advice.
Critical Care- Weaning from Feeding Tubes
- -Preparatory Phase
1. Determining ___
2. ____ assessment
3. ____ readiness? - -Weaning phase
1. Gradual increase in ___ + ___
2. __% by mouth for 3 days, stop tube feedings
3. Success=weight ___, ___, normal swallow, no ___ problems
- -Preparatory Phase
1. Determining readiness
2. Swallowing assessment
3. Psychological readiness? - -Weaning phase
1. Gradual increase in oral feeding + tube feeding
2. 75% by mouth for 3 days, stop tube feedings
3. Success=weight gain, hydration, normal swallow, no respiratory problems
Transitioning to Oral Feeding (Box 15-1, Groher & Crary, pg. 314)
- Identify a __ __ __
- Provide __ __ ___
- Ingest __ __ before a __ __
- Reestablish a __ __ __
- Provide a __ __ in the initial transition stages
- Document type and amount of all oral materials
- Keep track of the ___ it takes to consume a meal
- Document any ___ with the oral diet
- Involve the __ and __ in preferences for advancing the diet.
- Monitor __ ___, nutrition, hydration, and ____ status.
- Identify a safe oral bolus
- Provide intermittent tube feedings
- Ingest oral feedings before a tube feeding
- Reestablish a normal meal routine
- Provide a specific diet in the initial transition stages
- Document type and amount of all oral materials
- Keep track of the time it takes to consume a meal
- Document any complications with the oral diet
- Involve the patient and family in preferences for advancing the diet.
- Monitor swallow safety, nutrition, hydration, and respiratory status.
Quality of Life Decisions
- __ and __ significance of food
- Medical judgments about __ ___, treatment burdens, ___ and risk of __
- Patient directives, __ __
Definition of __ __ __
–Defined differently for each person
–Allow patients to define QOL for themselves
- Cultural and social significance of food
- Medical judgments about mental status, treatment burdens, prognosis and risk of aspiration
- Patient directives, treatment refusals
Definition of quality of life
Defined differently for each person
Allow patients to define QOL for themselves
SWAL-QOL Assessment
-SWAL-QOL created over a 3-year period Purpose: \_\_\_\_\_\_\_ -Uses: \_\_&\_\_ clinical practice -Review Forms -Video
-SWAL-QOL created over a 3-year period
Purpose: increase understanding of patient’s experience with dysphagia
-Uses: Asses and guide clinical practice
-Review Forms
-Video
End of Life Issues
- Nutritional Changes: decreased need for __&__
- Dehydration reduced swallowing, ___, and ___
- Swallowing difficulty as death approaches
- Sensory changes-
1. __ ___
2. __ ___ - ___ changes
- Nutritional Changes: decreased need for food and fluids
- Dehydration reduced swallowing, vomiting and urination
- Swallowing difficulty as death approaches
- Sensory changes-
1. Lax jaw
2. Dry mouth - Sleep changes
