Interpreting a Living Will after Stroke

Ethics Roundtable: Case Study

Mr. Duffy is 83 years old and is admitted to rehabilitation four weeks after a right thalamic CVA. As a result of his stroke, he has dysphagia, dysarthria, and left hemiplegia and is moderately-severely confused. When Mr. Duffy pulls out his nasogastric feeding tube, his physician decides not to re-insert it because of significant nasal tissue necrosis. The team recommends a gastrostomy tube because of his high risk for aspiration and inability to maintain nutrition and hydration with oral feeding.

Mr. Duffy has a Living Will that states he does not wish to have his life sustained with a feeding tube. He does not have a formal Durable Power of Attorney for Healthcare. His wife has dementia and his two daughters are making decisions for both parents. They are not sure about his wishes in this particular circumstance, but report that he said of a relative who died of cancer, "things went on too long because of that feeding tube."

After three days, Mr. Duffy is more alert and during a discussion about tube feedings he says "I' ll go for the works." His fluctuating alertness level makes it impossible for him to respond to this question again. His daughters feel he would not want the tube and suggest waiting to see if their father' s swallowing will improve in the next week before making a decision.

Questions to Consider

  • Who is the appropriate decision-maker in this case?
  • What options are available to the team?
  • Suggest an optimal solution in this case.

Related Readings

  1. Hare, J., Pratt, C., & Nelson, C. (1992). Agreement between patients and their self-selected surrogates on difficult medical decisions. Archives Internal Medicine. 152(5): 1049–1054.
  2. Tippett, D.C. & Sugarman, J. (1996). Discussing advance directives under the patient self-determination act: A unique opportunity for speech-language pathologists to help persons with aphasia. Am. J. SLP. 5(2): 31–34.

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