Name Brand Medically Necessary: Do Not Substitute
Charles Mason, MD; Amy Givler, MD
I first learned that Mr B was my patient when the radiologist called me early one morning. "We can't do the barium swallow," he said, "because Mr B keeps spitting it out on the table."
"Okay," I replied. "Send him back to his room." I am an attending physician in a teaching hospital. Late the night before, Mr B had been sent from the local veterans home to our emergency department, and the resident on my team had admitted him.
Outside Mr B's room, I looked over his records. Three days earlier he had stopped taking anything by mouth, including liquids and his medication for hypertension, depression, and agitation. Last night the veterans home staff hadn't been able to arouse him and had sent him to our ED. They suspected that he had had a stroke.
I walked into Mr B's room and introduced myself. He was sitting up in bed and alert—after his night of intravenous fluids. He could speak but he was confused. His legs were weak, which had kept him bedridden for months, but otherwise his examination was unremarkable.
I offered him a glass of water with a straw. He sucked a mouthful but I noticed he didn't swallow it. "Swallow that down, Mr B," I said. He swallowed, then sucked another mouthful. "Swallow again, Mr B." He swallowed.
I called Mr B's physician at the veterans home. Mr B had lived there for a year, having arrived after a long stint at the veterans hospital. Before that he had been homeless. There had never been any contact with family. Mr B had a long history of alcohol and drug abuse and had been diagnosed with dementia.
The trouble started in the early afternoon.
A nutritionist paged me while I was seeing my clinic patients."Dr Mason, the nutritional support team just met and discussed Mr B, your patient with the stroke, and we have several concerns. He hasn't eaten for 4 days now, and we want you to address his nutritional needs. We want to know how you are going to evaluate his dysphagia and feel you should place a feeding tube or start hyperalimentation until his problem improves or you decide to place a PEG tube."
"Thank you," I replied. "But I don't think he's had a stroke and I don't think he has dysphagia. I think he's just reached a point in his dementia where he can't remember to swallow. His albumin is normal, which tells me his diet has been adequate until recently. Try hand-feeding him, but be sure to remind him to swallow."
Silence. "I see," she said. "We'll try that. And what about the PEG tube? He wouldn't have to be put to sleep to put it in."
"I know that," I said, "but there's no evidence that PEG tubes benefit patients with advanced dementia."
More silence. "Thank you, Dr Mason," she said, "but I do hope you'll reconsider."
The next morning Mr B's CT scan report read, "Diffuse cerebral atrophy with no focal lesions." I entered his room and found it dark with Mr B asleep. I opened the blinds, awakening him, and saw that his breakfast tray was nearly intact. A few bites of scrambled egg were on his gown where he'd spit them out.
"Good morning," I said, pulling up a chair. I offered him a bite of scrambled eggs. He took it readily and then worked it to the front of his mouth. "No, no, Mr B, don't spit that. Swallow it."
Mr B swallowed the eggs.
I opened the milk carton, inserted the straw, and—with my prompting—he drank the milk down.
Outside the room, a nurse approached me. "Dr Mason, Mr B is spitting out all his food. I kept on feeding him, but then he choked. I spoke with the head nurse and we think he is at risk for aspiration. What about a feeding tube?"
"No, no, no," I replied. "He just needs to be told to swallow with each bite." The head nurse walked up. "Just now," I said, "I had no trouble getting him to eat and drink." Both nurses stared at me with pressed lips, their arms crossed. They think I want Mr B to suffer and starve, I thought.
I needed to get on with rounds. "Look," I said, "I'll consult the ethics committee, which is meeting this week." At that they looked satisfied.
The next day I found myself once again alone with Mr B in his room. His breakfast was untouched. "Mr B, do you get hungry?"
"Oh, yes, Doctor, sometimes I like to starve."
"Why don't you eat when the nurses feed you?"
"I don't know, Doctor. Nobody ever gives me no food I can eat."
I fed him a few bites of his oatmeal—reminding him when to swallow. "Mr B, we could do a small operation to put a tube in your stomach to feed you without your having to remember to swallow. Would you like that?"
"Oh, no, Doctor. I don't want nothing like that."
"Okay, Mr B. Don't you worry."
By noon three separate nurses had called me, concerned about Mr B's nutritional state. Finally I ordered peripheral hyperalimentation. "But only if he's able to keep a functional IV line," I said. I think I was yelling The next day was the ethics committee meeting. I spoke first. I presented Mr B's case, then plopped a pile of articles onto the table. "Here are recent articles that argue against the use of PEG tubes in dementia," I said. "What Mr B needs is careful hand-feeding with prompted swallowing."
"Thank you, Charles," said the committee head.
"Have you considered a nasal feed tube or central line hyperalimentation?" someone asked.
"He'd pull out a nasal tube," I replied, "and I think he'd refuse a central line."
"Then you must restrain him so the tube stays in."
"I will not order restraints on Mr B," I said.
The debate was lively. Had Mr B had a stroke? Was he competent—and so can legally refuse all procedures, as he is doing? Or was he incompetent—and can't consent to any procedure?
I left the committee meeting with homework—keep Mr B on peripheral hyperalimentation, get his veterans hospital records, and contact our hospital's attorney about the competence issue.
The next morning on rounds as I approached Mr B's room, I grumbled to myself, Why am I the only person who can get this man to eat? Then I stopped and thought, I don't have to be.
I went to the rear of the nurses station—past nurses who glared at me and then looked at each other knowingly—and grabbed a packet of crackers and a carton of milk. "Come with me, all of you," I called out to everyone at the station. "And send for the head nurse—and page the director of nursing too!"
When everyone was assembled at Mr B's bedside, I opened the cracker packet. "Are you hungry, Mr B?"
"Oh, yes, Doctor!"
I fed him a piece of cracker. He chewed slowly and then seemed to be preparing to spit. But I was watching for that. "Swallow, Mr B," I said firmly. He swallowed and then opened his mouth for another bite. He finished the saltines, then started on the milk.
Gradually the tense atmosphere in the room lifted. Hostile expressions changed into amazed ones.
"Mr B," I asked, "what do you want to eat?"
"Well, Doctor, I wish I had some Jimmy Dean sausage."
Now I'm a southern country boy too, so I knew that further clarification was necessary. "Patty or link?"
"Mild or spicy?"
The nurses were now caught up in the spirit of the situation. They peppered Mr B with questions. Soon a tray arrived from the kitchen with eggs, grits, and bacon—no sausage available. Mr B wouldn't touch the bacon, but I worked butter into the grits and he ate them eagerly. A nurse took over and I went back to get his chart. "Jimmy Dean mild patty sausage with every meal," I wrote.
The ward clerk smiled brightly as I handed her the chart. An hour later I got a call from the kitchen. Did I really want someone to go to the store to buy Jimmy Dean mild patty sausage?
"Yes, indeed," I replied.
The next day I discharged Mr B back to the veterans home. On his diet order I wrote, "Jimmy Dean mild patty sausage daily with breakfast. NAME BRAND MEDICALLY NECESSARY. DO NOT SUBSTITUTE."