NUR 3002

Tutorial 6 (Tutorial Version)

Case A (Mr. A lived in the USA)

Mr A is 70 years old but when he was in his early 60s he drew up an advance directive to forgo artificial
nutrition and hydration in end-of-life care, including tube feeding and intravenous therapy. He was not
cognitively impaired then. On admission to hospital, his wife and the clinical staff affirmed this directive.
Mr A could not recognize his wife and his ability to speak was largely impaired. He had sensitive skin that
required special care. He could not control his bowel or bladder. He spent most of the day in a
wheelchair because he could not move by himself. He did not eat well and had lost weight over the past
weeks. One day he developed an ulcer on his ankle and reddened skin over several pressure areas. The
ulcer became worse and two new ulcers developed despite the use of pressure relieving measures. His
wife worried about the deteriorating ulcers and the quality control nurse regularly reminded the ward
staff of possible substandard care. After exhausting all the extrinsic pressure-relieving interventions, the
clinical team eventually formed a clinical opinion that ulcers would not be controlled unless the patient’s
nutritional status improved. The option was to provide nutritional supplement through a feeding tube.

Case B (Mr. B lived in Hong Kong)

Mr B, an 89-year-old man lived with his adult son until one day he fell and broke both hips. Once
hospitalized, he was put on tube feeding and ordered conservative treatment for his fractured hips. He
was transferred to a long-term care facility after his condition had stabilized. He could not recognize his
loved ones but was responsive to them. He strongly rejected the feeding tube and made every attempt
to pull it out after reinsertion. His arms were restrained but despite this he appeared very determined to
get rid of the tube and tried every posture in bed to release himself from the constraints. Frequent
reinsertion of the feeding tube traumatized his naso-oesophageal passage, his mobility was reduced,
and friction and sheer force were increased. His adult son questioned whether it would be better to
forgo tube feeding. The nurses worried that he would develop pressure ulcers soon.

Discussion:

What are the ethical dilemmas for these two cases?

What ethical theories or principles you can apply for these two cases?

Source:

Davis, A. J., Tschudin, V., & De Raeve, L. (2006). Essentials of teaching and learning in nursing ethics:
perspectives and methods. Elsevier Health Sciences.
Case A

Not to institute any artificial nutrition (obligatory duty), nurses are held accountable to respect Mr A’s
advance directive (respect for autonomy, upheld in the Patient Self-Determination Act).

Or:

To institute tube feeding as a corrective therapy (obligatory duty), given that the patient is not likely to
die in a few days and his nutritional inadequacy may be reversible (beneficence).

Case B

To provide optimal comfort care to Mr B by withdrawing the tube (obligatory duty) because he does not
like it (substitute judgement based on respect for autonomy), and the tube is a source of discomfort
contributing negatively to his well-being (beneficence).

Or:

To continue tube feeding (obligatory duty) because to do otherwise will deprive Mr B of adequate
nutrition, which may hasten his death (beneficence in terms of removing the possible harms on the
patient’s life).

For details, please refer to:

Davis, A. J., Tschudin, V., & De Raeve, L. (2006). Essentials of teaching and learning in nursing ethics:
perspectives and methods. Elsevier Health Sciences. Chapter 8, pp 68-73.