ScenarioSubstitute Decision-Makers

Disagreement among substitute-decision makers

An older adult with Alzheimer’s disease develops pneumonia and is no longer able to tolerate oral intake and is not capable of making nutrition treatment decisions. The Speech Language Pathologist recommends tube feeding. The client has not left any instructions about what they would want done medically and has not provided a description of their values that would help guide their healthcare team in this situation. The client’s daughter and son share the substitute decision-maker (SDM) role. The client’s daughter disagrees with tube feeding and feels it would be against her father’s wishes. The son demands the tube feeding as he believes his father would starve to death without it.  How might you handle this

Consider holding a family meeting including the healthcare team to discuss the risks and benefits of enteral nutrition. It may be helpful to include an ethicist as well. The purpose of the meeting would be to help the siblings come to an agreement about the tube feeding.

Making an Application to the Consent and Capacity Board 

When a health care provider feels that SDMs are not acting in the client’s best interest and are putting the client at risk, they can apply to the Consent and Capacity Board for arbitration in the matter. The Consent and Capacity Board is an independent body under the Health Care Consent Act, 1996which considers matters relating to capacity, consent, and substitute decision-making. Section 37 of the Health Care Consent Act, 1996 states that a health care practitioner can apply to the Consent and Capacity Board if they believe that the substitute decision-maker does not have the capacity to give consent or is not complying with the principles given in Section 21(2).
In this scenario, if the RD and the healthcare team determine that they have reason to believe that the substitute decision-makers are not acting in the client's best interests or are themselves not capable of giving consent, they should consult their hospital administration and/or legal counsel before making a formal application to the Consent and Capacity Board. (Refer to the Professional Practice Standard, Consent to Treatment, p.12).

The Consent and Capacity Board will hold a hearing to determine If the  substitute decision-makers did not comply with their responsibilities, the Board can direct them to do so. If a substitute decision-maker is deemed not to have the capacity to give consent or does not comply with the Board's direction, another person may be appointed.