This case presents several fundamental ethical issues. The first issue is the patient’s refusal of treatment (a nasogastric tube [NGT] insertion). Second, the patient’s refusal of a seemingly beneficial treatment, combined with her medical history, ultimately necessitates an assessment of her decisionmaking capacity. Third, the sister’s reluctance to participate in decisionmaking requires a discussion of appropriate surrogate decisionmakers. Finally, the main ethical component to this case is a cultural one, which should be addressed appropriately.

The medical team found the patient to lack medical decisionmaking capacity. However, the team felt that the patient was still able to respond appropriately to some situations. KS had displayed a consistent refusal of all medical treatments that made her uncomfortable or caused pain. During her sister’s visits, the patient would be much more receptive to eating. A meeting was planned with the patient’s sister in which the ethicist explained that the patient was not able to make her own decisions. The patient’s sister agreed that she would honor the patient’s wishes but would let the team make any decisions outside of what she knew about the patient’s preferences. The patient’s sister agreed and was willing to be at the patient’s bedside as much as she could to encourage her eating. If the patient’s condition worsened, it was discussed that the team honor the patient’s wishes and not force a feeding tube on her. The patient’s code status was also addressed, and KS’s sister felt comfortable in communicating to the team that the patient would not want to be resuscitated if medical treatments would not be able to improve her current quality of life. A natural passing away would be most amenable to the patient. The patient was discharged to her nursing home with a physician order for life-sustaining treatment (POLST) form signed by the sister documenting a do-not-resuscitate code status with comfort-focused treatments.