79 y/o PMH of A fib, IDDM,

79 y/o PMH of A fib, IDDM, OSA, dysphagia requiring tube feedings and spinal fracture 2/2 MVA who presented as a transfer where he was diagnosed with pneumonia and sepsis. Current lives in a long term care facility. Request to transfer from family to your facility. Patient is bedbound at baseline. Receives feedings via PEG tube and is supposed to remain NPO; however, spouse and daughter admit to feeding him at time. Pt is in long term care facility due to spouse’s inability to provide 24 hour care for him on her own. Pt lethargic on admission. He does nod appropriately but otherwise did not speak during admission visit. Spouse is at bedside. Lengthy discussion held at time of admission regarding comfort feeding with DNR code status versus the need to follow recommendations to remain NOP if goal is to remain a full code. Pt has previously filled out an advanced care plan. Son reports the patient has voiced wishes for full code interventions and wants to honor his dad’s wishes. Daughter and wife want patient to return home and be able to eat and drink. They do not wish for hospice care and they just want to take their father home. “Our dad is strong”. He has not had any trouble eating until his accident earlier this year. The family requests an esophageal dilatation which he has had in the past and this would treat his dysphagia. Family requests removal of PEG tube as well as esophageal dilatation. GI consult was ordered/obtained: The GI consultant documents: On review of patient’s previous records, he has had 2 upper endoscopies which neither demonstrated a stricture therefore I do not believe a repeat EGD will benefit pt. Also in the state of patient status, unless pt is made hospice would be irresponsible for me to remove tube. Family requests 2nd GI Opinion. Pt discharged back to rehab facility and will seek the 2nd GI opinion. Answer the following questions: 1. What do you think of the families request to remove PEG tube and to stretch the esophagus so the patient can eat? 2. The GI consult was blunt with his response, what were your thoughts to that? 3. Do you believe that providers should do what families request? If so, why and if not, why not? 4. What concerns do you about the family if any? Would there be any other actions to be taken with or for the family in this type

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