Ethics Roundtable: Advance Directives, Autonomy, and Gastrostomy Placement.

CL is a 94-year-old male who is brought to the Emergency Department from an assisted living facility due to a new onset of weakness and altered mental status. He was in his usual state of moderately compensated health, requiring assistance for most activities of daily living due to medical frailty and a previous right brain CVA with residual mild left sided weakness. On the day of admission, the staff found him lethargic and disoriented. The family requested a surgical consult for percutaneous, endoscopic, gastrostomy (PEG) tube placement. A review of the patient\u27s records showed that the patient had refused a PEG tube during his last two hospitalizations. During the last admission, the hospitalist documented that the patient repeatedly refused nutritional support stating if it\u27s my time, I\u27ve lived a full life. I\u27m ready to die and join my wife. There was no advance care plan ( living will ), but CL did sign a Selection of Surrogate Decision-maker form previously, assigning his nephew as primary surrogate. Under pressure from multiple family members, including the designated surrogate, the attending requested a surgical consultation. The surgical team determined that the patient did not have capacity and scheduled CL for PEG tube placement. The care team had concerns regarding the conflict between the patient\u27s previously (and consistently) stated desires and the family\u27s wishes; an ethics consult was requested