[Dysphagia] Ethical Issues

[pressmah at sjhmc.org (pressmah@sjhmc.org)]

He does need to decide and indicate to his caregivers what his wishes are if
he develops a pneumonia that requires intubation.

-----Original Message-----
From: Benoit, Mia [PH] [mailto:MBenoit@providencehealth.bc.ca]
Sent: Wednesday, December 07, 2005 12:25 PM
To: Nancy Burnett; dysphagia-bounces@b9.com; Paula leslie; Dysphagia
List
Subject: RE: [Dysphagia] Ethical Issues


Ethically, if C is compentent and able to make his own decisions then he
should be able to eat if this is his choice. Maybe another honest talk about
the risks should be had and then it is C's decision. It becomes more
complicated if C is not competant and a substitute  decision maker needs to
be found. 
Everyone has the right to make decisions about their own quality of life and
what is important to them and I believe as health care professionals we must
respect that. 
Mia

-----Original Message-----
From: dysphagia-bounces@b9.com [mailto:dysphagia-bounces@b9.com]On
Behalf Of Nancy Burnett
Sent: Wednesday, December 07, 2005 5:48 AM
To: 'dysphagia-bounces@b9.com'; 'Paula leslie'; Dysphagia List
Subject: RE: [Dysphagia] Ethical Issues


Hi Paula,
It seems to me that C's wishes are paramount if he indeed is aware of and
cognitively able to weigh the risks and benefits of oral feeding. Perhaps
the compromise that is suggested ie honey and pudding consistencies with
aggressive oral hygiene would satisfy C and minimize his risk for chest
complications. Always in search of the "lesser of the evils".
Good luck...Nancy

Nancy Burnett,
Speech-Language Pathologist,
Cambridge Memorial Hospital,
700 Coronation Blvd.,
Cambridge, Ontario.
N1R 3G2
Telephone: 519 - 621 -  2330 ext 1126/Pager 1104
Fax: 519 - 740 - 4978  Attention Nancy Burnett 3BN
Email: nburnett@cmh.org


> -----Original Message-----
> From:	dysphagia-bounces@b9.com [SMTP:dysphagia-bounces@b9.com] On Behalf
> Of Paula leslie
> Sent:	December 7, 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.
> 
> Any advice or shared experience of similar situations would be very much 
> appreciated!!
> 
> 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
> 
> 
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