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Discussion Starter · #1 ·
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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Discussion Starter · #5 ·
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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Discussion Starter · #6 ·
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 :confused:
 

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Discussion Starter · #7 ·
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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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. :D
 

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Discussion Starter · #9 ·
Your rules will kill the patient

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. :D
So you agree on killing the patient. Stop the feeding and he will sure die within few days :confused:
 

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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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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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Discussion Starter · #12 ·
It's not killing the patient

So you agree on killing the patient. Stop the feeding and he will sure die within few days :confused:
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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Discussion Starter · #13 ·
Just rule out depression

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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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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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.
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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2010 question. hahaha

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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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 :D
 

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2010 question

I got the same question in my NBME and wanted to post it on the net when I found it already existed!Happy-2
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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