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  #1  
Old 03-10-2010
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Medicolegal and Ethics Terminal Care for an old dying man

An 81 year old Alzheimer patient is expected to die withing the next few months. He has been completely obtunded and uncommunicative but responsive to painful stimuli. He has not been eating for the last three weeks and is admitted to the hospital for nasogastric tube feeding. His wife states that he previously told her that he doesn't want artificial means to prolong his life. The patient has no living will or durable power of attorney. He has been pulling off the feeding tube on three different occasions last three days.
Which of the following is the most appropriate next step?

A- Discuss comfort care with his wife.
B- Recommend feeding the patient via a syringe.
C- Begin total parenteral nutrition.
D- Suggest a trial of Haloperidol that may prevent him from pulling out the feeding tube.
E- Schedule him for placement of percutaneous gastric feeding tube.
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  #2  
Old 03-10-2010
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Default Option A

I think A is the correct answer
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  #3  
Old 03-10-2010
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Probably D
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  #4  
Old 03-11-2010
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B,C,D,E don't seem right.but what is a about?
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  #5  
Old 03-11-2010
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Default Option A

This question is about the fact that the wife speaks with patient voice (since he's uncommunicative) and what she says has to be done. The patent does not want to prolong life by artificial means and because (he still feels pain) it means that he's pulling out the tube because it's painful and it should be removed.
Since the patient is going to die soon then it's probably best to discuss terminal care like strong analgesia and sedation (Option A)
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  #6  
Old 03-11-2010
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Quote:
Originally Posted by laithbv View Post
This question is about the fact that the wife speaks with patient voice (since he's uncommunicative) and what she says has to be done. The patent does not want to prolong life by artificial means and because (he still feels pain) it means that he's pulling out the tube because it's painful and it should be removed.
Since the patient is going to die soon then it's probably best to discuss terminal care like strong analgesia and sedation (Option A)
Yeah you are probably right but don't you think we are "killing" the patient if we don't feed him
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  #7  
Old 03-11-2010
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Default You should not stop feeding him

I remember Conrad Fischer once said "Even if the patient has a DNR in effect that does not mean you don't put NGT, DNR means that you don't "Actively" resuscitate the patient.

So I go with option E
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  #8  
Old 03-12-2010
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Default A

definitely A.
in kaplan it says

rule #4 of ethical and legal issues:

we can make the decision for the patient if he/she is incompetent on the basis of substituted judgement (wife speaking for him) and best interest standard (benefits vs burdens)

if the patient is indeed competent then see rule#6:
a competent person can refuse even lifesaving hydration and nutrition (via feeding tube)

so whether we think he's incompetent or competent, he or his wife can say stop the feeding. if there was an option saying wait for court's decision i would've picked that but i think they didnt wanna confuse ME here.
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  #9  
Old 03-12-2010
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Default Your rules will kill the patient

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Originally Posted by Seetal View Post
definitely A.
in kaplan it says

rule #4 of ethical and legal issues:

we can make the decision for the patient if he/she is incompetent on the basis of substituted judgement (wife speaking for him) and best interest standard (benefits vs burdens)

if the patient is indeed competent then see rule#6:
a competent person can refuse even lifesaving hydration and nutrition (via feeding tube)

so whether we think he's incompetent or competent, he or his wife can say stop the feeding. if there was an option saying wait for court's decision i would've picked that but i think they didnt wanna confuse ME here.

So you agree on killing the patient. Stop the feeding and he will sure die within few days
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  #10  
Old 03-12-2010
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I think I also agree on A here. It's not us that are in fact killing the patient, but instead it's us respecting a patient's decision to refuse treatment. Also, waiting for a court's decision doesn't seem right because a proxy exists who can make the decision.
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  #11  
Old 03-14-2010
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oh no rafiq. i would most definitely not agree in killing a patient but from kaplan notes what i understand is in the US we respect patients' wishes regardless of what we might think morally since morally we are subjective but the law is more objective. and what one might think is more morale may not be in another culture. (different cultures different believes). just like in certain states it is ok to do an abortion for a minor without parental concern. (a supreme court ruling i beckon strongly).

the general rule is: whatever patient wants, patient gets.

yes yes.. definitely not wait for a court ruling unless there is heaps of chance for survival (i think; im still weary on the waiting for the court ruling thingy)
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  #12  
Old 03-23-2010
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Default It's not killing the patient

Quote:
Originally Posted by Rafiq2010 View Post
So you agree on killing the patient. Stop the feeding and he will sure die within few days
Withholding the NGT is not considered suicide or "killing the patient" in US law. This is widely perceived as appropriate throughout all states.
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  #13  
Old 06-13-2010
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Arrow Just rule out depression

Quote:
Originally Posted by Rafiq2010 View Post
I remember Conrad Fischer once said "Even if the patient has a DNR in effect that does not mean you don't put NGT, DNR means that you don't "Actively" resuscitate the patient.

So I go with option E
The patient is fully competent and his wishes of removing the nasogastric tube should be granted.
Refusing NGT is just like refusing any other form of treatment, the patient has the rights to refuse it as long as you fully explain to him the consequences of removing the NGT.
The only exception to this rule is when the patient is actually attempting suicide, therefore you should rule out depression before allowing him to do so.
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  #14  
Old 06-16-2010
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Post Answer is E

Schedule for the placement of percutaneous Gastric tube.

As it is not an artificial means of life that you are providing - just the food that he needs, and you are alleviating the discomfort that the patient has because of the NG ube, E is the most sensible choice to make (Or so I hope)
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  #15  
Old 10-19-2012
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Default nutrition issues

I also agree with E .This is not sustaining life by artificial means it is providing nutrition.In a patient with DNR orders one will still carry on taking care of him you will not reduce the level of care or not operate on him for a treataable cause.Providing nutrition is not a way of sustaining life by artificial means.
Quote:
Originally Posted by tmsid View Post
Schedule for the placement of percutaneous Gastric tube.

As it is not an artificial means of life that you are providing - just the food that he needs, and you are alleviating the discomfort that the patient has because of the NG ube, E is the most sensible choice to make (Or so I hope)
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  #16  
Old 10-19-2012
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I will go with option A. It seems like the more "cover your ass" type option
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  #17  
Old 10-19-2012
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Default 2010 question. hahaha

Quote:
Originally Posted by Hohepa View Post
An 81 year old Alzheimer patient is expected to die withing the next few months. He has been completely obtunded and uncommunicative but responsive to painful stimuli. He has not been eating for the last three weeks and is admitted to the hospital for nasogastric tube feeding. His wife states that he previously told her that he doesn't want artificial means to prolong his life. The patient has no living will or durable power of attorney. He has been pulling off the feeding tube on three different occasions last three days.
Which of the following is the most appropriate next step?

A- Discuss comfort care with his wife.
B- Recommend feeding the patient via a syringe.
C- Begin total parenteral nutrition.
D- Suggest a trial of Haloperidol that may prevent him from pulling out the feeding tube.
E- Schedule him for placement of percutaneous gastric feeding tube.
Ya in these options
A seems most promising answer but if she says "she want to save the patient" in every possible way. Then what we should do?
As this patient don't have any living will or power off attorney.
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Old 10-19-2012
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Show Teeth

Quote:
Originally Posted by koolkiller88 View Post
Ya in these options
A seems most promising answer but if she says "she want to save the patient" in every possible way. Then what we should do?
As this patient don't have any living will or power off attorney.
IMO it doesn't matter if she wants to save him or not. This is what I make out of it. The guy seems incompetent to make his decisions. So we look up to the surrogate (spouse in this case) who will make decisions basing on what the patient would have wanted, as she was closest to the patient. These are my 2 cents people
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  #19  
Old 10-20-2012
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Default 2010 question

I got the same question in my NBME and wanted to post it on the net when I found it already existed!
Quote:
Originally Posted by koolkiller88 View Post
Ya in these options
A seems most promising answer but if she says "she want to save the patient" in every possible way. Then what we should do?
As this patient don't have any living will or power off attorney.
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  #20  
Old 10-13-2016
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probably AA
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  #21  
Old 10-14-2016
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Default Spot on

Quote:
Originally Posted by laithbv View Post
This question is about the fact that the wife speaks with patient voice (since he's uncommunicative) and what she says has to be done. The patent does not want to prolong life by artificial means and because (he still feels pain) it means that he's pulling out the tube because it's painful and it should be removed.
Since the patient is going to die soon then it's probably best to discuss terminal care like strong analgesia and sedation (Option A)
It's likely A
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