Cases:MrChan

Mr. Chan was an 84-year-old male, with a history of hypertension, diabetes and recurrent ischaemic stroke. His wife died a few years ago. He had two sons and one daughter living in Hong Kong. He was diagnosed to have vascular dementia five years ago and became chair-bound. For two years, he lived with his second son’s family, cared for primarily by his daughter-in-law Mary. However, Mr. Chan had gotten progressively weaker in the last few months and Mary no longer could transfer him out of bed alone. Mr. Chan was then brought to live at a private old aged home.

In the last year, he became bed bound and double incontinent and required assisted feeding. He also had recurrent hospital admissions due to chest infections and the speech therapist recommended puree diet and thickener in fluid. After an episode of aspiration pneumonia, the speech therapist suggested non-oral feeding due severe oropharyngeal dysphagia.

The doctor asked to meet with the family and the second son and the daughter came. His son said, “Father would not want to have a feeding tube placed. He had seen many tube-fed elderly people at the old age home. They just lied in bed all day and it was not a life that he wanted. He told us that he would rather die than have one put into him.”

The daughter had also heard her father express that and they both made the decision for careful hand feeding rather than tube feeding. They understood the risk of aspiration, pneumonia and death.

The patient tolerated careful hand feeding for several months. However, he then developed fever and became unarousable. He was transferred to the hospital and was found to have a severe pneumonia. He was kept nil by mouth and given parenteral antibiotics. His second son and daughter were informed of deteriorating clinical condition and imminent death. They understood and agreed to continue conservative management.

The next day, however, the oldest son turned up and insisted on starting tube feeding. He accepted that his father was dying and agreed to continue comfort care and continue DNACPR order. However, he said “It’s important that my father would die with a full stomach. I do not want him to become a hungry ghost.” The clinician was not sure whether he should simply reject the son’s request or not.

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• Nutrition and hydration
• Life-sustaining treatment
• Family conflict
• Dementia
• Cultural beliefs

– Dr. Tse Chun Yan, Chairman, HA Clinical Ethics Committee (2005 to 2017)ⁱ

Cultural factors are among various important contextual features that should be considered in clinical ethics case analysis. The Chinese may have some deep-rooted views about death and dying that the patient may value. Such views may have to be respected in suitable situations. However, this does not mean that traditional cultural views should be accepted without question. Cultural considerations have to be individualized and carefully weighed against other important considerations.

We can approach the problem step by step:

After reaching the conclusion that tube feeding should not be provided, the doctor had to handle the son’s request in an appropriate manner. Rather than just telling the patient’s son that he had no right to request the treatment, it would be better for the patient’s son to understand the rationale of the final decision. This would help to reduce conflicts and reduce guilt feelings in the son after the patient’s death. The doctor should explain to the son that treatment given had to be in the patient’s best interests, and that tube feeding would do more harm than good to the patient and was not in line with the wish of the patient. It would be useful to involve the other family members in the discussion, who might understand better the view of the healthcare team. If differences in opinion persisted despite thorough communication, the healthcare team was not obliged to provide clearly futile treatment not in the best interests of the patient. Adequate documentation of the rationale for the final decision should be made in the medical notes.

i The case and commentary was adapted from an article by Dr. Tse Chun Yan, “Practical Approach to Clinical Ethics at the Bedside for General Physicians”, published in Synapse, Newsletter of the Hong Kong College of Physicians, in August 2016. The case was originally presented by Dr. Wong Che Keung of Ruttonjee and Tang Shiu Kin Hospital on 23 April 2016 in the Clinical Ethics Day held in HA Head Office Lecture Theatre.