NURS 519 Week 7 Ethical Dilemma Paper on a Feeding Tube in Advanced Dementia Example

Feeding Tube or Careful Hand Feeding? An Ethical Dilemma Paper on a Divided Family and a Nursing Home Resident With Advanced Alzheimer's Disease

Step 1: Identify the Ethical Dilemma

The resident, a composite widow of 86 in the late stage of Alzheimer's disease, has lived in a nursing home for four years. She no longer speaks in sentences, cannot walk, needs help with every meal, and has had two aspiration pneumonias in five months. Her son, named as her agent for health decisions, has asked for a feeding tube because "I will not let my mother starve." Her daughter believes their mother would refuse it, recalling her saying after her own husband's long final illness, "Don't ever keep me alive on machines." The dilemma is whether to place a feeding tube to provide nutrition, which the son sees as an act of care, or to continue careful hand feeding focused on comfort, which may better honor her wishes and avoid harm. Both options aim at the resident's good, which is what makes this a dilemma rather than a question with a single right answer.

Step 2: Gather the Facts

The resident is at Stage 7 on the Functional Assessment Staging Tool, the last stage of Alzheimer's disease. She has lost 9% of her body weight in six months, pockets food in her cheeks, and coughs with thin liquids, and a swallow evaluation found unsafe swallowing with all textures. She has no written directive about artificial nutrition, but the daughter's report of her words is specific and was said in a relevant context. The son is the legal decision maker. The clinical evidence on outcomes is a central fact. A Cochrane review found no randomized trials of tube feeding in severe dementia and only low or very low certainty evidence from 14 non-randomized studies, which was not enough to show that tube feeding prolongs life or prevents pressure ulcers (Davies et al., 2021). In a propensity-matched cohort of people with advanced dementia, Yuen et al. (2025) found no significant difference in one-year survival between nasogastric tube feeding and careful hand feeding, but a 60% higher adjusted risk of pneumonia with the tube. In a Portuguese cohort of hospitalized older adults with advanced dementia, those discharged with a tube had more complications at one year with no survival benefit (Ramalho et al., 2026). Among more than 241,000 hospitalizations of people with dementia for gastrostomy placement in a United States national sample, procedure complications were not higher than in other patients, but people with dementia were much less likely to be discharged home (Goble & Leventhal, 2025).

Step 3: Identify the Stakeholders and Their Values

The resident is the central stakeholder, and her values must be reconstructed from her past life: she was a retired schoolteacher, a lifelong Methodist who led her church's meal ministry, and a person who said clearly what she did not want. The son values loyalty and protection; feeding has deep emotional meaning for him, and he fears that declining a tube means choosing her death. The daughter values honoring her mother's voice and sparing her suffering. The nursing staff value safety and are worried about aspiration during hand feeding, which takes time they do not always have. The facility, the physician and the hospice team, if engaged, value good care within the law and regulations. A qualitative review of 16 studies found that families and professionals alike describe feeding decisions at the end of dementia as emotionally loaded and say that clear communication and professional guidance are what make them bearable (Cai et al., 2026).

Step 4: Apply Ethical Principles

Respect for autonomy asks what the resident herself would choose. Because she cannot decide now, the standard is substituted judgment, and her reported words point away from a tube. Beneficence asks which option does her the most good; the evidence suggests a tube would not lengthen her life and would remove the comfort and social contact of being fed by hand. Nonmaleficence asks which option risks the most harm; the tube carries a higher pneumonia risk, procedural complications, and, if she pulls at it, a real chance of restraints, which Matzo and Sherman (2018) count among the burdens of artificial nutrition in dementia. Justice asks that she receive the same quality of care as any resident, including enough staff time for safe hand feeding. A Christian view adds that life is a gift from God to be protected, yet death is not the final enemy for the believer, and accepting its approach is not the same as causing it. Paul could write that "to live is Christ, and to die is gain" (English Standard Version Bible, 2001/2016, Philippians 1:21), a confidence that allows care to stop resisting a natural death while never abandoning the person who is dying.

Step 5: Identify Options and Consequences

Three options exist. The first is a percutaneous gastrostomy tube with continued feeding. Its likely consequences are reliable delivery of calories, no clear gain in survival, a continued or higher risk of aspiration from refluxed feeds, possible restraints, and loss of the pleasure and contact of meals; the son's distress would ease, while the daughter would feel her mother's wishes had been overridden. The second is careful hand feeding focused on comfort, sometimes called comfort feeding only: small amounts of preferred foods at her own pace, adjusted textures, upright positioning and stopping when she refuses. Its consequences are continued weight loss and an expected decline over weeks to months, with comfort, the mealtime company of staff and family, and fewer burdensome interventions. In a cohort of family caregivers in Singapore, prioritizing comfort care was associated with fewer burdensome medical interventions in the last year of life of people with dementia (Andres et al., 2025). The third option is a tube placed for a defined trial period with agreed goals and a set date to stop if they are not met, which some families find easier to accept, though stopping a tube later is often harder emotionally than not starting it. For this resident, a trial would have to name goals that could actually be measured within a month, such as weight stabilization and no new pneumonia, and the evidence makes the second goal unlikely to be met. A trial also exposes her to the procedure itself and to the tube's daily burdens during the period it runs. A fourth path, doing nothing until the next crisis, is not a real option, because it would leave the decision to an emergency department physician at two in the morning, without the family's reflection or the resident's voice.

Step 6: Make and Justify the Decision

The recommended decision is careful hand feeding focused on comfort, with hospice enrollment and a family meeting to reach agreement. This option best honors the resident's own words, avoids treatment the evidence suggests will not extend her life and may increase pneumonia, and keeps the human contact of being fed, which for a woman who spent years feeding others is part of who she is. The son remains the legal decision maker, so the decision has to be reached with him, not imposed on him. That point deserves weight because a surrogate who feels overruled may carry guilt into bereavement, and because a nursing home that sidesteps a legal agent risks both a complaint and the family's trust. The goal of the meeting is therefore not to win an argument with the son but to help him see the choice through his mother's eyes. A useful question is, "If your mother could sit with us for five minutes and see herself now, what would she tell us to do?" Many surrogates find that question changes the decision from "Am I giving up on her?" to "What would she want from me?", which is the substituted judgment standard expressed in plain language. At the meeting, the nurse and physician would explain the evidence plainly, acknowledge that his wish comes from love, and correct the belief that she is starving: in advanced dementia, reduced intake is part of dying, and people near death rarely feel hunger as healthy people do (Matzo & Sherman, 2018). The team would also offer the time-limited trial if he cannot accept the recommendation, since a shared decision is better than a decision the family later regrets.

Step 7: Implement and Evaluate

Implementation begins with the family meeting within the week, with the chaplain present if the family wishes, and a written plan of care that names comfort feeding as the goal. The speech-language pathologist teaches staff and family safe hand feeding techniques, the care plan assigns a consistent aide at meals, and the son and daughter are invited to feed her at lunch on alternating days. The physician writes orders for comfort-focused care, and the hospice team adds mouth care, symptom management and support for both children. Evaluation uses measures agreed in advance: signs of comfort or distress at meals, episodes of coughing or fever, use of restraints (target none), and, after the family meeting and again after her death, whether both children feel their mother's wishes were respected. If the son continues to struggle, the team revisits the decision with him rather than considering it settled. The MSN nurse who leads the plan also reviews it at the weekly interdisciplinary meeting, so that aides who feed her can report what they see and the team can adjust textures, timing or positioning before a problem becomes a crisis. The plan succeeds if she is comfortable and accompanied, and if her children can grieve without believing that one of them betrayed her.

References

Andres, E. B., Malhotra, C., & PISCES Study Group. (2025). The final year for community-dwelling older adults with dementia in an Asian setting: Admissions, interventions, and caregiver burden. The Journals of Gerontology: Series A, 80(12). https://doi.org/10.1093/gerona/glaf227

Cai, M., Gong, X., Yang, Y., He, H., & Wu, X. (2026). Views and experiences of people with dementia, informal caregivers and professionals on eating and drinking difficulties: A qualitative systematic review. Journal of Advanced Nursing, 82(10), 8921-8938. https://doi.org/10.1111/jan.70547

Davies, N., Barrado-Martín, Y., Vickerstaff, V., Rait, G., Fukui, A., Candy, B., Smith, C. H., Manthorpe, J., Moore, K. J., & Sampson, E. L. (2021). Enteral tube feeding for people with severe dementia. Cochrane Database of Systematic Reviews, 8, CD013503. https://doi.org/10.1002/14651858.CD013503.pub2

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Goble, S. R., & Leventhal, T. M. (2025). Complications of gastrostomy tube placement in patients with dementia: A national inpatient analysis. Surgical Endoscopy, 39(8), 5001-5007. https://doi.org/10.1007/s00464-025-11923-x

Matzo, M., & Sherman, D. W. (Eds.). (2018). Palliative care nursing: Quality care to the end of life (5th ed.). Springer Publishing Company.

Ramalho, A. R., Rocha, M. J., Magalhães, J. A., Santos, N., Santana, I., Veríssimo, M. T., & Santos, L. (2026). Feeding-related hospitalizations and outcomes in advanced dementia. European Geriatric Medicine, 17(2), 897-905. https://doi.org/10.1007/s41999-025-01366-x

Yuen, J. K., Bernacki, R., Chan, F. H. W., Chan, T. C., Chow, D. T. Y., Shea, Y. F., Ng, B. L. H., Chan, K. M. K., Li, X., Shi, Q. M., & Luk, J. K. H. (2025). Comparison of survival and pneumonia risk in advanced dementia patients on nasogastric tube feeding versus careful hand feeding. The Journals of Gerontology: Series A, 80(9). https://doi.org/10.1093/gerona/glaf165