Ethical considerations
The four principles of medical ethics – autonomy, beneficence, nonmaleficence, and justice – can guide clinicians, patients, and family members in decision-making. In our case, by withholding needed and desired treatment (discharge to and treatment by a rehabilitation facility) the patient is being coerced to undergo a procedure he does not want, and clinicians participate in denying him autonomy. Further, given that the evidence, national guidelines, and in fact federal regulations indicate that his preferences are congruent with best practices, pressuring him to accept gastrostomy placement runs afoul of the principles of beneficence and nonmaleficence. Though the mechanism is unclear, early gastrostomy (<14-21 days) is associated with increased risk of death, worse functional outcomes, and a lower rate of return to oral feeding, as well as a significant procedure-specific complication rate.1,10 By insisting on gastrostomy, we neither act in this patient’s best interests nor “do no harm.”
However, the medical system is complex. The clinician at the bedside can evaluate this scenario, review the national guidelines, discuss the procedure and risks with the patient and family, and conclude that the patient should be discharged with a nasal feeding tube. Nevertheless, if no facility is willing to accept him without a gastrostomy, our decision-making model – previously limited to our patient’s best interests alone – is forced to change. Despite our misgivings, we often conclude that the harm done by an early gastrostomy is outweighed by the harm of remaining unnecessarily in the acute hospital setting. We further worry about other patients lingering in the emergency department for lack of an inpatient bed and the possible – though unknowable – harm done to them.
Looking forward
It is an unfortunate fact that medical decision-making must often include factors unrelated to the patient’s best interests, with financial considerations and structural barriers frequently driving deviation from ideal care. Providers and patients navigate these decisions to their best abilities, making compromises when forced. However, with education and professional activism, providers can advocate for the elimination of barriers to providing medically sound and ethically appropriate care. In our experience, delay of gastrostomy placement, until discharge is imminent and planning for postdischarge care is initiated, has resulted in a decrease by half the fraction of patients with tracheostomies who had gastrostomies placed prior to discharge.11 With aggressive outreach and education, we now have nursing homes willing to accept patients with NGTs.
Criteria for admission to discharge facilities can drive medical decision-making that is unethical and unsupported by evidence. Continued efforts to eliminate barriers to appropriate and ethical care have been successful and are encouraged.
Dr. Cowan is administrative chief resident in the department of surgery at Columbia University Irving Medical Center, New York. Dr. Seres is professor of medicine in the Institute of Human Nutrition and associate clinical ethicist at Columbia University Irving Medical Center. The authors have no conflicts of interest to disclose.
References
1. Dennis MS et al. Lancet. 2005 Feb 26-Mar 4;365(9461):764-72.
2. Powers W. et al. Stroke. 2018 Mar;49(3):e46-e110.
3. Burgos R et al. Clin Nutr. 2018 Feb;37(1):354-96.
4. Wilmskoetter J et al. J Stroke Cerebrovasc Dis. 2016 Nov;25(11):2694-700.
5. George BP et al. Stroke. 2017 Feb;48(2):420-7.
6. Fessler TA. et al. Surg Endosc. 2019 Dec;33(12):4089-97.
7. Burgermaster M et al. Nutr Clin Pract. 2016 Jun;31(3):342-8.
8. Moran C and O’Mahoney S. Curr Opin Gastroenterol. 2015 Mar;31(2):137-42.
9. Gomes CA et al. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD008096.
10. Joundi RA et al. Neurology. 2018 Feb 13;90(7):e544-52.
11. Bothra A et al. J Parenter Enteral Nutr. 2018 Feb;42(2):491.
