P.O. was a ninety-five-year-old man with dementia admitted to the hospital with a severe infection. He was admitted to the intensive care unit, and a “Do Not Intubate” order was written. Unfortunately, his mental status did not return to base-line. When he still had acute delirium, a speech therapist determined that he was at high risk for aspiration. His physician wrote the NPO order, and requested a gastroenterologist consider putting in a percutaneous endoscopic gastrostomy (PEG) tube. 

The clinicians told his wife that if he were allowed to eat he would be at high risk for the food to go to his lungs and that could kill him. After a very brief conversation, his wife consented, and a PEG was placed. The nurses needed to apply physical restraints to Mr. P.O.’s wrists to prevent him from pulling on the PEG tube or his oxygen mask.

The conversations with the family shifted to focus on transferring him to a post-acute facility for further care. The hospital’s social worker spoke to Mr. P.O.’s daughter Naomi. Naomi appreciated the opportunity to talk with the social worker and let her know important additional information regarding Mr. P.O’s history that the doctors were not aware of, and that her mother did not volunteer. 

P.O. was born in Warsaw, Poland in 1925. During WWII he saw family and friends die of disease, and starvation. He witnessed brutal murders of those he knew and did not know. At the end of the war, he was the sole survivor of his family and weighed just 84 pounds. He met his wife at a train depot the following year. She was immediately attracted to him because he had a shiny red apple in his hand, that he polished continuously. Somehow, she convinced him to share that extremely rare commodity with her. After that, they never left each other’s side.   

Naomi was clearly emotionally stressed by the way the discussion around the feeding tube went. The family was initially reluctant to consent to not let him eat. They knew how important eating was to him. They did not want to take that pleasure away from him. Eating was one of the few pleasures that his dementia had not yet robbed. He could not speak intelligible words, was incontinent, could not sit up independently, and did not smile when his daughter or wife spoke to him. He did smile, smack his lips, and made a pleasure sound when ice cream was put in his mouth. The ice cream had to be a flavor that he liked (pistachio). 

However, when the hospitalist said in a very strong voice, “You don’t want him to starve to death do you?” his wife reluctantly signed the consent form, and wrist restraints applied. Several times he was given injections of haloperidol when he became “agitated”.

After transfer to the skilled nursing facility, Mr. P.O.’s family was educated about the typical course of dementia, and given a brochure from the Alzheimer Society. They learned that feeding tubes have not been shown to improve the quality or duration of life in dementia patients, and that the recommendations of the American Geriatric Society were not followed. That a thorough evaluation of alternative feeding options should have been conducted before initiating parenteral nutrition. 

They also learned that the device they were told would reduce aspiration, often causing pneumonia and other infections. The staff of the facility told them that they have cared for numerous dementia patients that they fed in a manner that reduced the chances of pneumonia. 

Around one week after SNF admission, and much discussion, P.O.’s family requested that he be fed, and asked for the PEG to be removed. Their doctor then told them that although we could begin the modified diet recommended by the facility’s speech therapist, they had to wait four weeks to remove the tube. After the PEG was removed, the clinicians were able to reduce and then eliminate the medications prescribed for agitation. 

P.O. seemed to enjoy what he was fed (especially the pistachio ice cream), and had no medical complications from eating. Unfortunately, he was not able to consume enough calories and lost weight.  He was admitted to Hospice, and died with his family and caretakers at his bedside. In one hand he held his wife’s hand and in the other a shiny red apple.   

(The preceding is a composite of several actual true life events.)