This essay describes a case study of a patient name Dr Jeremy Armstrong. He is a 78-year-old patient. He was married for 40 years, and he used to love his wife Joan. His wife died recently. Dr Armstrong has a 48-year-old son name James. He is married to Claire. Dr Armstrong also has a sister name Shirley.The patienthad a stroke at the age of seventy. Later he noticed that he is suffering from memory loss, but the test result showed that he is okay. However, there have been several fatal occasion that indicated that he is suffering from some mental illness. He wanted to take mental assessment test andfirst he scored twenty-seven and then seventeen out of twenty in MMSE (Mini-Mental State Examination) test. Doctor diagnosed that he was suffering from Vascular Dementia and Alzheimer Disease at the age of seventy-four. After his wife died, things gone out of control and he had to get admitted in the hospital. The healthcare providers forced him to consume his food by tube after they faced difficulties in feeding him with a soft diet. His repeated rejection did not get the notice of any health care provider. In addition, they breached many laws of human rights and fed him forcefully by tube. It is illegal to forceful tube feed any older Dementia patient. The following paragraphs will explain the nursing care, empowerment and collaborative care that can be applied for this specific case study. The essay will also include the law and ethical concern of the incident.
In the case study, the primary nursing problem that is found is the application of nasogastric feeding of Dr Jeremy Armstrong. His profile suggested a background that he is a 78-year-old man. He had a stroke at 70 years old. LaterHe was diagnose with Alzheimer disease and Vascular Dementia and prescribed with Aricept, an anti-dementia medication. After he admitted to the hospital, Jeremy developed the urinary infection; however, it was relieved by the use of an antibiotic. Some timeAfter by doing the reassessment, doctors found that Jeremy scored the MMSE (Mini-Mental State Examination) 8 out of 20. His score reduced from his previous score due to several strokes. The caregivers observed that he was facing difficulties in the oral intake due to coughing.
It was frequently found that using a feeding tube for elderly has a higher risk due to ethical concerns and health impairment of the old people (Alagiakrishnan, Bhanji and Kurian, 2013). In this scenario, Jeremy was suggested to consume soft food. however, his family and the health care providers faced difficulties in feeding him by hand. Due to lack of nutrition he could have develop malnutrition (Hansonet al., 2013). That can lead to increased chance of cognitive impairment. Dr Armstrongfaced difficulty in deciding about theswallowing and chewing of the food and was forced to feed by the naso-gastric tube.The tube feeding can result in nausea, vomiting and diarrhoea in senior citizen (Baijenset al., 2016).It also causes high blood sugar and heart diseases even stroke (Meierand Ong, 2015).Death can be the result. In thiscase, of Dr Armstrong,he has several health issues that can lead to infections at the site of the tube. Additionally Jeremy was diagnosed with Alzheimer disease, and he is taking anti-Alzheimer medicine. The tube feeding can enhance the psychological symptoms. Jeremy could miss the pleasure of the oral food intake and may miss the family gathering during the dinner and lunch. It is very important to reduce such kind of depression, in following scenario, there are no such measures were seems to be taken to reduce such depression. Jeremy was also detected with Vascular Dementia, according to the guidelines for the tube feeding the dementia patients may pull out their feeding tube, as they are not able to understand the consequences. This type of incident can cause a terrible hazard to his health.Dignity and comfort is the primary right of a patient, and every patient has a right to choose their own option. In the case of Dr Armstrong, he should have given a chance to decide his own will about if he wants the food tube or not. However, the decision was not taken from him. The doctors and his family decided to use the application of nasogastric feeding system. The reason behind this was the difficulty they were facing to feed him in the normal ways. However, the results was harmful for his health. They should have searched for other alternatives. Use of food pureed could have been more justified for him. This type of interventions is very effective as this technique is the traditional way to deliver the food by hand. Occasionally Alzheimer patients feel difficulty in deciding whether they should swallow the food or not. This technique needs special attention of the caregiver, as any minimum sign that shows the patient’s lack of interest in the food the caregiver should not force him and stop feeding him. This technique can be difficult sometime as this can take lots of time. The caregivers and the family members need to keep their calm to feed the patient. However, this is the best way to feed him without risking his dignity or comfort level.
Empowerment in nursing can be defined as a technique that can deliver the health care to the patient in such a way that the patient can make the decision for his or her own health care needs. In another way, it can be said that the medical team and the healthcare team should need the permission of the patient before they can make any decision that is related to the patient’s health care needs, without the permission of the patient it is not ethical to apply any severe health technique (Renedoet al., 2015). This will allow the patient to feel free about their ability to involve in the decision-making with the healthcare professionals (Regan,Laschinger. and Wong, 2016). This technique can also help to build innate ability about the issue they are facing. Nurses can use the strategy to educate the patient about the informed decision-making, different options of the treatment and also provide information about the self-management (Buchanan, 2016). In this case, scenario, the patient Dr Armstrong was not given any options but to accept whatever treatment is provided to him. The healthcare department did not take any concern about the empowerment of the patient before the application of nasogastric feeding. The patient should have given a chance to make his own decision about whether or not he wants it. This lead to the disempowerment of the patient. The patient was not even educated about the situation he was facing. Further, in the case study, we have seen that the consensus reached to the further decision about letting the patient out in fast-track discharge when they realize that the situation is out of hand and the patient does not have much time in his hand. The family of the patient also contributed to their decision that the patient should stay in the hospital as the case is sensitive. None of the authorities was concern about the interest of the patient. Dr Armstrong should have given a chance to make a decision about what he wanted in his last days. The hospital staffs and the family of the patient should have made a more collaborative effort to provide the patient with the freedom of knowledge and choices about his own health care decision. The collaborative strategies of the hospital staffs and the family of the patient should be provided him with more person-centred care, which consists of educating the patient about the situation he is facing. In addition rather than feeding him with the help of nasogastric feeding, hand driven feeding should have given priority. It would have helped him in developing personal and psychological comfort to the patient. It is known by the case study that the patient was suffering from Alzheimer Disease and Vascular Dementia. In this kind of situation the patient fails to recognise any food items and refuse to swallow it. This phase is known as oral-phase dysphagia. Dementia found to be the most basic cause for dysphagia. In this situation the care providers and family should have kept their calm to feed the patient by hand. They needed to be more attentive to the objections of the patients and address it. This process takes time but the success rate of recovering the patient is much higher than the nasogastric feeding (Snyderet al., 2013).
The case study suggests that Dr Armstrong after having a stroke was readmitted to the hospital. He could only communicate through his hand gestures and his nods as his speech and swallowing wascrucially affected. The speech development therapist advised him not to take his diets orally as that can cause congestion and he can chock. This can lead to the risk of inhalation in him. The medical staff decided to pass a nasogastric tube. Although on many occasions the patient had pulled out the tube,the caregivers did not take any concern about this and in addition, they discussed the need of PEG with consent from his son.Dr Armstrong tried to indicate occasionally about his disagreement about the tube feeding but that did not raise any ethical concern among any of the health care providers. The legal issue went further when the case study involved a written consent from the patient of ten years ago stating that he does not want any needlesspractice or interventions if he ever becomes a ‘cabbage’.There are four pillars of ethical practices in the case of the healthcare industry such as beneficence, non-maleficence, autonomy and justice (Nascimentoet al., 2018). This case study included the direct violence of one of these act that is the autonomy, whichincludes the respect for patients legal right to choose his own health care needs (Schwartz, 2018). The autonomy includes confidentially, access to record and consents (Holmes, 2016).
In this case study the patient Dr Armstrong was not given any chance to choose his own medical needs. He was developing difficulties in swallowing, so the medical staff decided the use of nasogastric tube without any permission from the patient. The patient can communicate by nodding and hand gesturing. He tried to indicate occasionally that hedo not want to use a feeding tube. He expresses his interest to feed orally. In several occasions, he tried to pull out his tube in order to indicate his rejection towards the treatment. However, the healthcare providers even his family denied to accept his moral right and forcefully fed him by the use of the nasogastric tube. The patient’s record suggested that he wrote a consent ten year before stating that if he becomes affected by any of disease that can make him ‘cabbage’ he does not want any unnecessary medical interventions to be applied on him. Both the medical care team and his family denied his consent and directly breached his ethical right to self-decided healthcare. They also suggested putting PEG for his treatment.According to Human Rights Act (1998) of united kingdom when an older patient who is suffering from Dementia, is clearly indicating his refusal to eat by pulling out his feeding tube that means he is not wishing for the food (Millerand Appelbaum, 2018). Forcing him to eat the food by feeding tube clearly violates the persons decision of not staying alive (Mitchell, 2015). The patient is being forced to stay alive without his or her decisions. In fact, this act can lead to the conclusion that the patient is clearly being assaulted by the continuous presentation of food that he does not want to consume. The act stated that any forceful act to feed a Dementia patient could be illegal and not ethical (Bateset al., 2015).
In this case, the forcing food through the feeding tube in to the mouth of Dr Armstrong is clearly not ethical judging from the parameter of this act. For this kind of scenario, the act suggests the caregivers to a soft offering of the food repeatedly to the patient and let him make his own decision. This technique can take time but it is effective for any kind of Dementia patients. The patients should be encouraged continuously to eat his food. In the United Kingdom the history if Dementia patients showed a poor demonstration of outcomes, so the tube feeding of any older Dementia patient is very rare in the United Kingdom and in the rest of Europe (Goldbergand Altman, 2014).
Conclusion:
The conclusion can be drawn from the above case study that the patient Dr Armstrong who is a 78-year-old patient who severely suffered from heart diseases and other old age diseases was suddenly diagnosed with Vascular Dementia and Alzheimer disease. He score for the MMSE test to examine his logical and cognitive state seemed to be gradually lowering. The last test suggested his score eight out of twenty. He was also suffering from difficulties in swallowing and speech. He tried to communicate with hand gestures and nods but the health care providers and his family seemed to be less concern about his choices about his medical needs. The healthcare providers and his family collaboratively agreed to use the nasogastric tube to feed him. However, the patient deliberately indicated he want to drink orally and pulled out his tube. Although the patient tried his best to reject the treatment, the healthcare providers breached the Human Act Rights and the ethical autonomy rules and forcefully feed him. His family also encouraged this act and they agreed to further use of PEG tube. The patient also provide a letter clearly state do not to use any kind of unnecessary technique on him when he becomes mentally and physically challenged, the caregivers and family ignores it and proceed with the act. Australian Human right law discourages the force feeding of Dementia patients as this kind of action breaches the ethical concern of a old Dementia patient. This type of act should not be practiced in a Nursing care practices as this clearly hampers patient dignity or comfort level. Nurses should empower the patient with the proper education with the help of collaborative help of patient and the health professionals. Violation of patient’s morality can lead to fatal condition of a patient, which is directly against the law and ethical practices.
References:
Alagiakrishnan, K., Bhanji, R.A. and Kurian, M. (2013). Evaluation and management of oropharyngeal dysphagia in different types of dementia: a systematic review. Archives of gerontology and geriatrics, 56(1), pp.1-9.
Baijens, L.W., Clave, P., Cras, P., Ekberg, O., Forster, A., Kolb, G.F., Leners, J.C., Masiero, S., Mateos-Nozal, J., Ortega, O. and Smithard, D.G. (2016). European Society for Swallowing Disorders–European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clinical interventions in aging, 11, p.1403.
Bates, E., Bell, C., O’Cinneide, C., de Londras, F., Dzehtsiarou, K., Edward, D., Greene, A., Johnson, P. and Lock, T. (2015). The legal implications of a repeal of the Human Rights Act 1998 and withdrawal from the European Convention on Human Rights.
Buchanan, D.R. (2016). Promoting dignity: The ethical dimension of health. International quarterly of community health education, 36(2), pp.99-104.
Castro, E.M., Van Regenmortel, T., Vanhaecht, K., Sermeus, W. and Van Hecke, A. (2016). Patient empowerment, patient participation and patient-centeredness in hospital care: a concept analysis based on a literature review. Patient education and counseling, 99(12), pp.1923-1939.
Goldberg, L.S. and Altman, K.W. (2014). The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical interventions in aging, 9, p.1733.
Hanson, L.C., Ersek, M., Lin, F.C. and Carey, T.S. (2013). Outcomes of feeding problems in advanced dementia in a nursing home population. Journal of the American Geriatrics Society, 61(10), pp.1692-1697.
Holmes, D. (2016). Critical interventions in the ethics of healthcare: Challenging the principle of autonomy in bioethics. Routledge.
Meier, C.A. and Ong, T.D. (2015). To feed or not to feed? A case report and ethical analysis of withholding food and drink in a patient with advanced dementia. Journal of pain and symptom management, 50(6), pp.887-890.
Miller, F.G. and Appelbaum, P.S., 2018. Physician-assisted death for psychiatric patients—Misguided public policy. New England Journal of Medicine, 378(10), pp.883-885.
Mitchell, S.L. (2015). Clinical practice. Advanced dementia. The New England journal of medicine, 372(26), pp.2533-2540.
Nascimento, A., Carvalho, M., Nogueira, J., Abreu, P. and Nzwalo, H. (2018). Complications Associated With Nasogastric Tube Placement in the Acute Phase of Stroke: A Systematic Review. Journal of Neuroscience Nursing, 50(4), pp.193-198.
Regan, S., Laschinger, H.K. and Wong, C.A. (2016). The influence of empowerment, authentic leadership, and professional practice environments on nurses’ perceived interprofessional collaboration. Journal of nursing management, 24(1), pp.E54-E61.
Renedo, A., Marston, C.A., Spyridonidis, D. and Barlow, J. (2015). Patient and Public Involvement in Healthcare Quality Improvement: How organizations can help patients and professionals to collaborate. Public Management Review, 17(1), pp.17-34.v
Schwartz, D.B. (2018). Enteral Nutrition and Dementia Integrating Ethics. Nutrition in Clinical Practice, 33(3), pp.377-387.
Snyder, E.A., Caprio, A.J., Wessell, K., Lin, F.C. and Hanson, L.C. (2013). Impact of a decision aid on surrogate decision-makers’ perceptions of feeding options for patients with dementia. Journal of the American Medical Directors Association, 14(2), pp.114-118.
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