Key point
Identifying goals which can be reviewed after a time limited period will make further discussions about prolonging or withdrawing alternative or clinically assisted nutrition and hydration. This encourages the conversation to be about achieving the patient’s best interests rather than only prolonging life and therefore:
- Confirms the outcome of the trial period of alternative or clinically assisted nutrition and hydration with very little evidence of benefit
- Acknowledges the consistent message from his wife about the patient’s known preferences
- Supports the whole team and allow them to express concerns about withdrawing alternative of clinically assisted nutrition and hydration balancing that with the risks of establishing longer-term alternative or clinically assisted nutrition and hydration
- Highlights the need for caution in discussions with family as there are current values differences between wife and daughter that will need to be dealt with sensitively
Where there is disagreement between members of the healthcare team about whether clinically assisted nutrition or hydration should be provided, it is important to seek resolution.
Listening carefully and trying to understand each team member’s perspective is important as it provides guidance and facilitates shared decision making. The following table provides some examples of what could be discussed within an MDT meeting and what layers of context can be contained within each statement.
| Things people might say | Reason for disagreement |
|---|---|
| He’s not had long enough to improve | Uncertainty of prognosis |
| I would find it very difficult to say | Personal discomfort with discussion |
| I’d need to ask my senior | Unsure related to experience |
| We can’t just starve him | Different values |
| We can’t withdraw a tube now we have started | Lack of clarity on the legal position |
| I wasn’t aware his family thought that | Insufficient sharing of information |
Scene 1
The team share their findings …
Scene 2
Junior Doctor
“The patients wife approached me yesterday. She was very emotional and said she is regretting agreeing to the tube. She says they had promised each other they would not allow this to happen. She also said she would not want her daughter to hear her saying this as she would think she was letting him down.”
Scene 3
Physiotherapist
“I am quite worried about his wife. She asked to join me on his physio session and was very quiet. She then said he wouldn’t want this. He has had no problems with his chest but is very passive and there is no progress to report. His daughter wanted to know how long before he can sit in the wheelchair.”
Scene 4
Nurse
“I think he is attending a bit more. He appeared quite upset when his family left last night and I am sure he likes to have them around. Sometimes I think he is trying to assist when we are moving and washing him. I think he is too stable to stop feeding.”
Scene 5
Speech Language Therapist
“I have reviewed his swallowing regularly but he is making little to no attempt to move the food in his mouth. He is coping with his own secretions with a spontaneous swallow and his chest is clear. He has made no progress in communication and has no consistent established means of expressing yes or no.”
Scene 6
Dietitian
“I was reviewing his weight and charts last week when his daughter asked me for my thoughts on PEG tubes and how this could help her dad. That was a little difficult to answer but I said we would need to review the benefits of the NG tube first and that there are risks in progressing to a PEG tube. She did however, request more information to read.”
Scene 7
Occupational Therapist
“Although I haven’t been working with him, his daughter has also asked me how she starts thinking about adaptations to his house. She was talking about making the sitting room into his bedroom and how to fit in a hoist … His wife appeared quite overwhelmed by the whole situation.”
Page last reviewed: 16 Jan 2023
