A 92-year-old man with Alzheimer’s disease has been aclmittecl to the hospital with
aspiration pneumonia. He is on a ventilator and has a nasogastric tube in place. He
does not have the capacity to understand his meclial condition. You find a living will
jn an old chart that says
“No heroic measures,” “l want to be DNR,” and “I wish to be
kept comfortable.” There is no proxy and there is no farnily available with whom you
can cliscuss the natter. He has no pr ivate physician with lvhom you can discuss the
case.
What should you do regarding the ventilator and tube feeding?
. Continuc both for now.
b. Remove the ventilator and the tube feeding.
c. I{emove the nasogastric tube but continue the ventilator.
d. Seek a court appointcd guardran.
e. Decide rvhat vor.r think is best for the patient
(a) Continue both for now.
'fhe major difficulty with the living rcill is that it is often rot clear and specific in
terms of what it means. The phrase “no heroic measures” is not sufficiently clear as
an advance directive to stop a ventilator that thc person’s life is dependcnt upon, You
also do not larow if the patient’s wishes have changccl since the last visit. As far as you
know, the paticr.rt’s famiJy may appear any minutc and say the patient wants to be on
a ventilator as long as it is not permanent. 'l’hey
may say
“no heroic measurcs” neant
dialysis and organ transplantation in the mind ofthe paticnt. A DNR order docs not
frean ren]ove a ventilator. DNI{ just means no cardiopulmonary resuscitation efforts
in the event of the patient’s death.If the advance directive is not clear, particularly concerning basic nutrition, then 1’ou
should continue therapy until it becomes clear If you think that what is best for the
patient is to rernove the ventilator and he dies, what happens when you find out that
the Alzheimer’s disease is mild memory impairment and “no heroic measures” in the
patient’s nind meant no chenothcrapy or surgery? Continue therapy until the situation is clear. In absence of a spccific directive to stop, you should continue.