The Case of John: Refusal to Eat in a Long-Term Care Facility

John is a ninety-two-year-old widower of many years who has exercised his bachelor skills in his tiny bungalow and enjoyed the occasional invitation to a neighbor’s home for dinner. He and his wife were childless, and no relatives have appeared for as many years as the neighbors can recall. He is a pleasant man, content with his own company, his dog and his yard. The woman across the street, after not seeing John for a few days, knocked at his door. When she could not get an answer, she reached under the welcome mat where she knew John kept a key. She let herself into his tiny home and found him in bed, unconscious.

John was taken to the hospital where pneumonia was diagnosed. Although the pneumonia was cured by antibiotics, his six-day stay left him weakened and confused. Mary, his neighbor across the street, was able to sign checks for John on his bank account since she had been getting his groceries for years. Although she was not officially named as his durable power of attorney for health care decisions, she was the person with whom the doctors and nurses had communicated. When it was time for John to be dismissed from the hospital, Mary suggested he be moved to the nearby long-term care nursing facility. She promised to look after his house and dog.

For a week now he has been in the long-term care facility; he hasn’t spoken, but he is awake and responds to simple commands. He has been fed in the assisted dining room. This morning, John raised his hand over his mouth when the aide attempted to feed him some oatmeal. She tried applesauce; again, he raised his hand to cover his mouth. She offered him coffee and he raised his hand again. She called for the supervisor who suggested that she continue feeding her other patients. The supervisor began talking to John and offering him small bites of breakfast. He responded with the same hand movement. John was returned to his room without breakfast.

The nurses on John’s wing discussed the situation. When lunch time came, John was wheeled out in his chair and again he raised his hand in front of his mouth when the first bite of food was offered to him. Even when the food was slipped in from the side, John’s hand reached over to cover his mouth.

The medical director of the facility was called. He did not know John, nor was there any other physician who had cared for him over the years. The neighbor across the street knew of no time when John had ever gone to a doctor. When Mary was asked if John had ever expressed any wishes about his eventual care, all she answered was that John had told her the cemetery in which he wanted to be buried.

John had been a member of First Church of Spring Valley, but he had not attended services for a number of years. The nursing home director called the minister who came to the facility with a member of the congregation who was a long-time worshiper and remembered John. In the discussion about John’s refusal to eat, the two church representatives disagreed over the issue of whether letting John continue not to eat was sinful or not. “He’s starving himself to death,” the long-time parishioner said. “No,” the minister countered. “I think it’s rather the case that John is simply ready to go to God and he doesn’t want his time on earth prolonged.”

The facility’s staff was divided. Some of the nurses thought John was expressing his natural inclination to stop eating. Others were not sure that John was alert enough to know what his gesture meant. Some asked, “Was there any ‘clear and convincing evidence’ that John knew what his hand gesture indicated?” In the absence of any such evidence, should a feeding tube be inserted?

A meeting is called by the administrator of the facility who asks the medical director; Mary, the neighbor; nursing staff representatives; and church members to attend.

Questions:
1. How can John’s capacity for decision making be determined? Must it be through the services of a professional?
2. If John is judged to be decisionally capacitated and thus his hand gesture means he no longer wants to eat, discuss the following distinctions:
• between “suicide” and “letting nature take its course”
• between nourishment as ordinary or extraordinary means (Does the fact that John can no longer feed himself point to nourishment as ordinary or extraordinary?)
• between oral and non-oral communication (Are they equally valid?)
3. What argument would you make to allow John to die? How would you answer the charge that you are supporting his committing suicide?
4. What special role, if any, should Mary play in helping the team decide what to do?
5. To what extent should John’s general physical state of health and life expectancy be taken into consideration?
6. Is the fact that death by starvation generally is considered painless morally relevant?

Prepared by Rosemary Flanigan, Director of Ethics Committee Development and Education Midwest Bioethics Center, Kansas City, Missouri.