Shady Brook skilled nursing facility is facing a legal and ethical dilemma with the care of their patient Mary Evelyn Greene. Mrs. Greene is 89 years old and suffers from the onset of mild dementia as well as other declining health issues related to aging. Although she became depressed over losing her independence and home upon being admitted to this facility, she seems to be pleased with her overall stay here up until her son, David, visits her. David acts as the power of attorney for his mother and deals with her personal affairs. Caring for his mother has become a major responsibility and quite difficult to deal with on his own. As of late, tending to his mother has begun to interfere with his work life. The nursing staff have become aware of his inimical attitude towards his mother and his thinning patience when visiting. Theyve documented that she seems happier in his absence and agitated in his presence.
Mrs. Greene has become too weak to eat on her own and often leaves much of her food on the tray. A CNA that she has grown fond of, Susan Brown, steps into sit with her and feed her when she is able to. Even though her desire to eat has declined and she has gradually lost her appetite, Mrs. Greene has never expressed to the medical staff at Shady Brook that she would like her food to be withheld or that she wished to die. In fact, she seems to still enjoy the smell of certain foods even when she has no appetite, and also responds positively to volunteers who carry out activities at Shady Brook. Therefore, her sons request to respect his mothers wishes of allowing her to die a quick death by not eating, came to the nursing staff as a surprise. Mrs. Greene has not exhibited any suicidal behaviors or expressed suicidal thoughts, which is why the nursing home administrator, Betty Wright, is concerned with whether she should trust his decision and motives.
This becomes a legal and ethical dilemma as the ethics committee must examine the patients rights, the states laws related to assisted suicide, the patients mental capacity, their best interest and stay within the legal realm of their facilitys operations. With the threat of a lawsuit coming from Mrs. Greenes son, the ethics committee must make a decision that not only reflects the best interest of Mrs. Greene but also protects their organization legally.
Mrs. Greenes rapidly declining health and weight loss should have alerted the nursing staff that there was a need for reevaluation of her plan of care. A weight loss of more than 5 pounds a week should have triggered the immediate attention of her healthcare providers. It is the job of skilled nursing facilities to ensure that the quality of life for each client is maximized and to prevent their decline in ability to perform activities of daily living. While it was appropriate to monitor and document her food intake and reactions to certain foods, it is ineffective to record data without seeking ways to improve the issue. Once it was realized that Mrs. Greene no longer possessed the ability to feed herself, someone should have been assigned the task of feeding her or her family/power of attorney should have been notified that the facility was unable to provide this service for her care so that they could assess other options. Even if it meant that the sitter hired by David scheduled her hours around feeding times to assist.
There are a few legal dilemmas for Shady Brook in this case. To start, Mrs. Greenes son, who is also her power of attorney, is requesting that the facility withhold food from his mother. However, doing so would be illegal as it is equivalent to assisting in murder. By law and buy contract the nursing home is required to provide Mrs. Greene with care that aligns with best care practices and avoid negligence in duty to their client. It is also difficult to determine her legitimate wishes as she suffers from dementia induced memory impairment. Therefore, her wishes/decisions for her own care could change from moment to moment. This makes it illegal to pursue the wishes that her son claims she had as we are unaware of what her mental state may have been, especially due to the agitated state that David evokes from her. On these legal basis, not even the power of attorney is able to instruct the facility to incriminate themselves.
A large portion of the ethical dilemma for Shady Brook in this case lies in the sons wish to enable the death of a relatively healthy person. While his mother may not be in the best health condition, she is far from being in a vegetative state and is still full of life. The only time that the nursing staff has experienced her in an agitated state is during and after visits with her son. Ethically, the facility feels the need to alleviate any suffering that their client feels, even if she wishes to die, which in this case they are unsure of due to her dementia. They do not wish to play along and assist Mrs. Greene in a quick death and are unsure of the motives surrounding his threats of a lawsuit. They must also be careful not to allow this threat to prevent them from doing what is right. This situation has progressed beyond the point of suggesting that Mrs. Greene be moved to a different facility because they realize that this is not in her best interest and would not aid her in anyway. Lawfully, the patient does not have a right to die and therefore David does not have a case. Because Mrs. Greene is not in a vegetative state, withholding proper nutrition and encouraging death would be illegal.
The ethics committee should continue to serve Mrs. Greene meals and provide a staff member to feed her. The previously documented reactions that she had to certain meals should be assessed to see which ones she reacted positively to. These meals should be the ones that are prepared for her to eat. Because Mrs. Greene has already loss a large amount of her body weight due to malnutrition, the ethics committee should also consider tube feedings to ensure that she is getting the proper amounts of nutrients daily and to prevent/reverse dehydration and malnutrition, especially if she has lost her appetite or has no desire to eat. It May even become necessary to solicit a nutritionist to be heavily involved in Mrs. Greenes plan of care. Many dementia patients suffer from dysphagia. If the foods are difficult for Mrs. Greene to swallow, then the nutritionist may be able to recommend foods that are easier for her to eat. They may also be able to suggest foods that have high nutritional value and aide in treating depression holistically.
By serving Mrs. Greene foods that she enjoys the smell of, it may increase her desire to eat even if she lacks an appetite. In doing so, Shady Brook would be fulfilling their legal obligation to care for their patient by making provisions to provide personalized plans of care. Mrs. Greene would also benefit by being served foods that bring her joy and increase her desire to indulge. This has the potential to boost her mood as well as her weight. Both consequences work in her favor.
On the other hand, providing her with a tube feeding would protect Shady Brook from negligence but increases liabilities as tube feedings have much more room for error. Mrs. Greene must also be assessed to ensure that her body will be able to properly process the feedings and use the nutrients. If not, the supplement will do more harm than good as it sits in her stomach. If she is eligible for such feedings, Mrs. Greene may welcome the idea. It would prevent her from having to deal with the frustrations associated with meal and feeding times. It would also improve her nutritional health state. By involving a nutritionist in Mrs. Greenes plan of care Shady Brook is ensuring that she receives the best nutrition plan possible for her individual condition. This protects their organization and benefits the overall well-being of their client, Mrs. Greene.
Essentially, if it is Mrs. Greenes wish to die by not eating then she can. Although Shady Brooks is required to serve her a meal, she has the right to refuse to eat it, but the meal must be served regardless. She also has the right to refuse feeding assistance. These instances of refusal should be documented in the event that negligence is suspected. Because of Mrs. Greenes mental state her power of attorney, David, may need to be consulted as well.
I would recommend that the ethics committee continue to serve Mrs. Greene meals, preferably those in which she has reacted positively to previously. I would also recommend that they assign someone to sit with her and assist during feedings. When available, this person should be Susan Brown since she has taken such a liking to her. Her appetite seems to improve when Susan assists her as well. This relationship and attention to detail in her care has potential to improve her overall condition. The additional attention could aid in her depression as well, as she seems to enjoy it and thrive from it.
The ethics committee should take into consideration Bettys comment that David needs the money to educate his children. Being that he seems to be the sole heir to his parents estate it appears suspicious that he is so adamant about allowing her death. Although he has presented it as his mothers own wishes, it very well could be his own, especially considering that no nursing staff previously reported suicidal behaviors or statements from Mrs. Greene.
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