Five Professions and a Daughter at One Table: Interprofessional Shared Decision-Making About a Feeding Tube in Advanced Dementia
[Student Name]
University of Phoenix
NSG/508: Leadership and Policy Development
Week 5 Assignment
[Instructor Name]
[Date]
The patient, family and team are a composite written for a model paper. No real patient is described.
A composite 86-year-old woman with advanced Alzheimer disease was admitted from a memory care residence with aspiration pneumonia. After treatment, she was alert but no longer opening her mouth for most spoonfuls and was losing weight. She had not recognized her family for a year, spoke only a few words and depended on others for all care. A surgeon was consulted about placing a percutaneous endoscopic gastrostomy tube, and her daughter, who held health care power of attorney, said, "We can't just let her starve." The question before the team was not a technical one about whether a tube could be placed; it was what care would honor the woman her mother had been and serve the person she now was. The nurse practitioner who led the hospitalist team convened an interprofessional meeting to help the daughter decide. This paper examines that process.
The Evidence the Team Shared
Before the meeting, the nurse practitioner asked each team member to review the evidence so the team would speak from a common base. Teno et al. (2012), studying a national cohort of nursing home residents with advanced dementia who developed eating problems, found that feeding tube insertion was not associated with longer survival, regardless of the timing of insertion. The geriatrics society's position statement concluded that feeding tubes are not recommended for older adults with advanced dementia, that careful hand feeding should be offered instead because it is at least as good for outcomes of death, aspiration pneumonia, functional status and comfort, and that tube feeding is associated with agitation, greater use of restraints and complications such as tube-related problems and emergency visits (American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee, 2014).
The team also recognized the limits of that evidence. It is largely observational, and it describes averages rather than this patient. It could inform the decision but not make it.
A Model for Interprofessional Shared Decision-Making
The meeting followed an interprofessional shared decision-making model (Légaré et al., 2011) that extends shared decision-making from a two-person encounter to a team. The model describes steps that include making explicit that a decision must be made, exchanging information about options, clarifying the values and preferences of the patient and family, discussing feasibility, making the decision and supporting its implementation, with different professionals contributing at each step according to their expertise.
Each Profession's Contribution
Six people met in a family conference room for 50 minutes: the nurse practitioner, the surgeon, a speech-language pathologist, the patient's bedside nurse, a chaplain and the daughter, with the palliative care nurse practitioner joining by video.
The nurse practitioner opened by naming the decision and its purpose: to decide together how to support the patient's nutrition and comfort in a way that fit her values. She asked the daughter to describe her mother before the dementia. The daughter spoke of a retired seamstress who loved church suppers and had told her, years earlier, that she never wanted "to be kept alive by machines."
The speech-language pathologist explained her swallow evaluation: the patient had oropharyngeal dysphagia typical of advanced dementia, and a tube would not remove the risk of aspiration from her own saliva. She described careful hand feeding with small amounts of preferred foods at the patient's pace.
The surgeon explained that the procedure was technically feasible and low risk to perform, but that the evidence did not show a survival benefit in advanced dementia, and he noted that he would place the tube if the family chose it after understanding this.
The bedside nurse described what she saw: the patient accepted small tastes of pudding and her daughter's homemade custard, pulled at her oxygen tubing and would likely pull at a feeding tube, which could lead to restraints.
The chaplain helped the daughter talk about her fear that choosing hand feeding meant giving up, and her faith community's views on food as care.
The palliative care nurse practitioner explained that decreased eating in advanced dementia usually reflects the disease itself, that people at this stage typically do not experience hunger as a person with healthy cognition would and that the team would treat any sign of discomfort.
Managing Disagreement
Disagreement surfaced in two places. The surgeon was initially inclined to schedule the procedure because the consult had been requested, reflecting a surgical culture of responding to referrals with procedures. The nurse practitioner had spoken with him beforehand, which allowed him to present the evidence neutrally rather than as a recommendation. The daughter's brother, reached by phone during the meeting, insisted on the tube. The nurse practitioner invited him to hear the evidence and his sister's account of their mother's wishes, and asked him what he thought his mother would say. After a pause, he agreed that she would not have wanted it.
The Decision and Its Implementation
The daughter chose comfort-focused careful hand feeding without a tube. The team documented the decision, the reasons and the patient's previously expressed values. The speech-language pathologist wrote a hand-feeding plan for the memory care residence, the nurse practitioner completed a portable medical order form reflecting the decision about artificial nutrition and the palliative care team arranged follow-up with the residence. The daughter was reminded that the decision could be revisited at any time.
After Discharge
The decision did not end at the hospital door. Two weeks later, the memory care residence called because a new aide was struggling to feed the patient and worried that the facility would be blamed if she lost weight. The palliative care nurse practitioner visited, demonstrated the hand-feeding plan and reviewed the documented decision with the residence's nurse, which reassured staff that the plan was deliberate and supported by the family. Interprofessional decisions often fail in the transition to a new setting where the people who made them are absent; writing the reasons, not only the order, and arranging a follow-up contact kept this one intact.
Leadership Lessons
Three lessons emerged about leading interprofessional decisions. First, preparation matters: the conversations the nurse practitioner held before the meeting, especially with the surgeon, shaped a meeting in which evidence was presented consistently. Second, leadership means structuring the conversation, not dominating it; the nurse practitioner spoke least of all the clinicians after her opening. Third, the patient's values, voiced through the family, must anchor the decision; the professions supply evidence and options, but the choice belongs to the patient's representative.
Conclusion
A decision about a feeding tube for a woman with advanced dementia required the evidence, the expertise of five professions and the knowledge of the daughter who knew her mother best. Using an interprofessional shared decision-making model, a nurse practitioner prepared the team, structured the meeting, managed disagreement and supported the family toward a decision consistent with the evidence and with the patient's values. The case shows interprofessional practice as a leadership skill that produces decisions no single profession could reach alone.
References
American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. (2014). American Geriatrics Society feeding tubes in advanced dementia position statement. Journal of the American Geriatrics Society, 62(8), 1590-1593. https://doi.org/10.1111/jgs.12924
Légaré, F., Stacey, D., Pouliot, S., Gauvin, F.-P., Desroches, S., Kryworuchko, J., Dunn, S., Elwyn, G., Frosch, D., Gagnon, M.-P., Harrison, M. B., Pluye, P., & Graham, I. D. (2011). Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. Journal of Interprofessional Care, 25(1), 18-25. https://doi.org/10.3109/13561820.2010.490502
Teno, J. M., Gozalo, P. L., Mitchell, S. L., Kuo, S., Rhodes, R. L., Bynum, J. P. W., & Mor, V. (2012). Does feeding tube insertion and its timing improve survival? Journal of the American Geriatrics Society, 60(10), 1918-1921. https://doi.org/10.1111/j.1532-5415.2012.04148.x
How this NSG 508 Week 5 example is structured
The University of Phoenix library guide for NSG/508 lists Week 5 as Interprofessional Practice and Decision-Making. The paper uses a high-stakes, evidence-rich decision because it tests every part of interprofessional practice at once: shared evidence, distinct expertise, conflicting professional instincts and a family's values. A published interprofessional shared decision-making model gives the meeting its structure, and the reflection section draws leadership lessons that apply beyond this case. Students search this week as NSG 508 Week 5, NSG508 Wk 5 or NSG/508 Wk 5; all three are the same assignment.
NSG/508 Week 5 questions, answered
What does NSG/508 Week 5 usually ask for?
The University of Phoenix library guide for NSG/508 lists Week 5 as interprofessional practice and decision-making. Many sections ask for a paper on how an advanced practice nurse leads or participates in interprofessional decision-making, often with a model of collaboration or shared decision-making applied to a case.
What does the evidence say about feeding tubes in advanced dementia?
Studies have not shown that feeding tubes prolong survival, prevent aspiration pneumonia, heal pressure injuries or improve comfort in people with advanced dementia, and they carry risks and often lead to restraints. The American Geriatrics Society recommends careful hand feeding instead.
Who leads an interprofessional family meeting?
Whoever is best placed to coordinate the team and the family, often the attending clinician, a palliative care clinician or the nurse practitioner managing the patient. Leading means structuring the conversation and making sure every relevant profession and the family are heard, not deciding alone.
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