Kwame, a stroke patient
| Kwame, an 83-year-old man who lives alone, has had a sudden right hemiplegia and is aphasic. A formal speech and language therapy assessment has identified Kwame as having a high risk of aspiration with any oral intake. Nasogastric tube (NGT) feeding was tried. However, Kwame repeatedly pulled out the NGT, so the multidisciplinary team decided to insert a nasal loop which allowed it to stay in longer. At 2 weeks, Kwame was referred for a gastrostomy. His relatives report that when his sister had a stroke, he had said, ‘You must shoot me if I am ever like that.’ Currently, he lacks capacity to consent to any procedure. Should Kwame have a gastrostomy? |
| The natural history of eating and drinking problems after a stroke will inform this decision. Serial assessments and the elapsing of time following an acute neurological event allow the potential for recovery to be estimated. Usually a patient is fed by an NGT for 10–14 days as an interim measure before a gastrostomy is considered. Insertion of a gastrostomy tube after 14 days reduces mortality and improves nutritional outcomes at 6 weeks compared with continued nasogastric feeding.10 A proportion of patients will regain swallowing function within the first 2 weeks; at 4 weeks 20% of patients will no longer require tube feeding.20,21 |
| Gastrostomy tube placement should not be an emergency procedure and should always be undertaken as a planned elective procedure, following clinical optimisation, in accordance with the patient's best interests, and with the agreement of the multiprofessional team. Pressure to place a gastrostomy early just to help facilitate faster discharge from hospital should be resisted. |
| Ad hoc or ‘off the cuff’ comments that do not specifically pertain to personal circumstances can result in an extremely emotive reaction from relatives. The facts surrounding such comments need to be explored and the clinical similarities or differences and/or origin of the concerns ascertained. While these views should be factored into best interests discussions and clinical assessments, they do not have any legal bearing on decision making if everyone is clear that they were off the cuff and not related to the person's own circumstances. Circumstances and opinions may also change and therefore too much weight should not be placed upon ad hoc comments made historically. |
| Patients may refuse treatment through an advance decision which is legally binding. An advance decision to refuse life-sustaining treatment has to be written, witnessed and clear that it applies even when life is at risk. Even if there is no advance decision to refuse treatment, if the patient's views can be ascertained with sufficient certainty, they should generally be followed or afforded great respect and will generally prevail over the very strong presumption in favour of preserving life. If a gastrostomy is not in the patient's best interests or goes against the patient's refusal (if they have capacity), inserting the gastrostomy tube could give rise to a charge of assault. |