Nasogastric tubes: a narrow dispute

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing and medical staff rely on when caring for patients.

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Mr W, a 77 year old man with end stage dementia, lacked capacity to make decisions about his treatment. Admitted to hospital in September 2017 with an acute illness, a nasogastric tube was passed to enable his enteral feeding. Within two months, he was well enough to return home, but his discharge was delayed due to a disagreement with his family. The dispute centred on whether he should go home with the nasogastric tube in place for continued provision of nourishment and hydration.

On numerous occasions in the ensuing six months in hospital, his tube was displaced and re-passed, with consequential significant abrasions to his nares and radiography after each replacement. W had no motor or verbal response to stimuli other than opening his eyes when his hand was pushed. The court was told that his GCS was 4; he suffered contractures, and had lost both his swallow and any signs of hunger. He was doubly incontinent, and entirely dependent on others for his personal care.

During the ensuing court hearing to settle where W’s best interests lay in the dispute over nasogastric feeding at home, it was agreed that W should be discharged to the care of his sons, with domiciliary clinical support. It was also agreed that insertion of a gastrostomy was not in his best interests, and nor was cardiopulmonary resuscitation.

The sons meanwhile sought a declaration that W should be discharged with the nasogastric tube in situ, whilst the Trust pleaded for a declaration that he should be allowed to go home with a plan for palliative care and oral comfort feeding, following removal of the nasogastric tube prior to discharge.

The hospital’s case was that long term NG feeding of adults with dementia in the community is rare, with a paucity of evidence measuring safety and efficacy. Nasal and oesophageal trauma associated with tube insertion, together with aspiration and tube dislodgement, were all commonplace and rendered home NG feeding unsafe for W.

The family’s view differed. They felt W had tolerated eight months of feeding in hospital well, and that they could significantly reduce the risk of displacement by providing continuous care at home. W’s sons had received training in tube care, and they noted the acknowledged risk of aspiration in the absence of a tube. W’s son, in evidence, reported that his father ‘never wanted to go back to hospital’, and had been a stoical man. At the High Court, the Trust’s application was granted.

On appeal, the court noted that the High Court judge had taken careful account of evidence of W’s wishes, feelings, beliefs and values. She accepted that he would have wanted to be cared for at home, but not that there was dependable evidence that he would have wished to receive continuing feeding by NG tube. She accepted the medical view that this was inappropriate, and that this view was consistent with NICE and GMC guidance. She also gave careful consideration to the risks and benefits of the different methods of feeding. Contrary to the family’s assertion that the High Court had not given enough weight to what W would have wanted in these circumstances, and that the judge had overstated the risks of tube feeding at home, the Court of Appeal found no error in her decision, and upheld the Trust’s application.

This case, turning as it does on the single issue of whether or not an elderly patient should go home with nasogastric tube feeding echoes a very common practical problem facing acute hospital trusts across the country. The court found that the patient’s best interests had precedence over the family’s (undoubtedly well-intentioned) insistence that tube feeding must continue after discharge. Demonstrating that on occasion, judicial authority is necessary to ensure that patients’ welfare is given priority.

Robert Wheeler
Department of clinical law, August 2018