Posts Tagged ‘Johns Hopkins Hospital’

Tube Feedings May Not Help Emaciated, Bed-Ridden Patient

DECEMBER 18, 2000 VOLUME 8, NUMBER 25

Frail, demented nursing home patients can eventually lose the ability to take food and fluids by mouth. When that process begins to occur tube feedings may be started. Doctors and family members may believe that such feedings prolong life and improve the ability to fight bedsores and disease. Dr. Thomas Finucane, a nationally recognized expert practicing Geriatric Medicine at Johns Hopkins in Baltimore, challenges that easy assumption. In a report for Elder Law Issues, Dr. Finucane explains:

Although it seems implausible, when faced with an emaciated, demented, permanently recumbent, poorly communicative patient with bedsores who is losing weight, clinicians and loved ones should remember there is no good evidence that administering tube feeding will help this patient.

Randomized trials are the gold standard for evaluating whether treatments are effective. Such trials are generally lacking with respect to tube feeding. Other data, some quite persuasive, have been developed, and these studies are virtually unanimous in showing lack of effectiveness.

Several lines of evidence suggest that tube feeding will not prolong survival when compared to a conscientious effort at hand feeding. Death rates are very high in the days and months after feeding tubes are placed.

No published paper suggests that tube feeding will reduce the risk of aspiration pneumonia; several trials find feeding tubes to be risk factors for the development of pneumonia. Aspiration pneumonia usually arises from inadvertent inhalation of either contaminated oral secretions or of regurgitated gastric contents. Tube feeding could not be expected to prevent either of these events.

Pressure sores have not been shown to improve when tube feeding is given. Once feedings are initiated, patients will produce more urine and stool, which are definite risk factors for pressure sores.

Risk of infection has not been reduced among tube fed patients. Serious and fatal infections have been shown to result from tube feeding.

Demented patients have not been shown to get stronger and function better with tube feeding.

Although it is difficult to know the experience of a noncommunicative person, there is no evidence that tube feeding reduces suffering. Restraints are more often used in tube fed patients.

Dozens of serious side effects have been reported as a result of tube feeding. Based on these data, it seems that tube feeding is overused in the care of patients with advanced dementia.

Legal battles over tube feeding have focused on comparing the benefits and burdens of the procedure. Benefits have been assumed, and burdens have usually been limited to the physical pain associated with insertion of tubes. Dr. Finucane challenges both sets of assumptions. He also challenges the medical community to undertake research to determine whether tube feedings really are beneficial.

Dr. Finucane’s analysis of medical studies, “Tube Feeding in Patients With Advanced Dementia,” was published in the Journal of the American Medical Association. Read the abstract or order his paper at http://jama.ama-assn.org/issues/v282n14/abs/jsc90078.html

Generic Living Will May Not Prevent Life-Sustaining Care

JULY 5, 1999 VOLUME 7, NUMBER 1

In nearly every state, living wills and health care powers of attorney can effectively declare a patient’s wishes regarding medical treatment and authorize an agent to carry out those wishes. In some states, the two kinds of documents may be combined into a single form, and they may be known by different names (“health care proxy” or “statement of wishes regarding health care,” for example). The ability of patients to direct the kind of care they will receive or not receive is seldom at issue. What frequently leads to legal complications, however, is how the directives are to be interpreted, when they become effective, and who must abide by them.

A recent Maryland court case illustrates the kinds of problems encountered in the practical use of advance directives. Robert Lee Wright thought he had taken care of the whole advance directive issue. He had signed a living will in the form set out by Maryland law, and had named his mother as his health care agent. These steps were not taken lightly; Mr. Wright had recently been diagnosed as suffering from AIDS, and his health care was an important and pressing issue at the time.

In July, 1994, Mr. Wright was at Johns Hopkins Hospital for treatment of kidney problems. He expected to undergo a blood transfusion and then return home. Instead, immediately after the blood transfusion he suffered cardiac arrest; within ten minutes of his heart failure, hospital staff had performed CPR. Mr. Wright’s life was saved, but he remained comatose for two days. He had apparently suffered brain damage during the cardiac arrest, and after he awoke from the coma he could only moan and call for his mother. He died ten days after the administration of CPR.

Mr. Wright’s parents brought suit against Johns Hopkins Hospital, alleging that his living will had instructed that he not be treated aggressively, and that hospital staff should have sought her permission (pursuant to the health care power of attorney) before resuscitating him. The trial judge dismissed the complaint, and the parents appealed.

Maryland’s Court of Appeals agreed with the hospital and the lower court. Mrs. Wright testified that both she and her son understood the living will to mean that “in the event it came [his] time to go, [he] did not want any life-sustaining procedures performed on him,” but the Court noted that the forms he signed did not make such a broad statement.

Mr. Wright’s living will and health care power of attorney, provided by Maryland law as a form for easy use, required that two physicians certify that he was in a terminal condition and that his death was imminent. Since no doctors had yet certified Mr. Wright as terminally ill, his directives were not yet effective at the time he underwent the blood transfusion in the hospital.

Does an individual have a legal cause of action when the hospital (or physician) provides care in violation of the individual’s advance directive? Yes, the court ruled, there is such a cause of action. Because Mr. Wright relied on the formulaic directives provided by the statute, however, Mrs. Wright could not show that the hospital had acted incorrectly. Wright v. Johns Hopkins Hospital, April 20, 1999.

Arizona law also provides a form advance directive for the patient’s convenience. That form does not require physicians to certify that the patient is terminally ill, though a “terminal condition” is mentioned in more than one place. Nothing in Arizona law, however, limits the applicability of living wills or health care powers of attorney to terminal conditions. Just as in Maryland, a patient could make a broader statement of his or her wishes. As in all legal matters, it is important to carefully read the form and make sure it properly expresses your wishes.

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