1. Dr. M. Ganeshananthan

2. Case 2 84 yr female NH resident for 3 yrs Long standing schizophrenia with limited communication Change in personality and deterioration in memory over the last year Dependent on staff for personal care and feeding Poor swallow on a soft diet

3. Case 2 On a good day can take a few steps (Has wheelchair) Otherwise needs help of 2 to transfer from bed to chair 4 admissions in the last year with chest sepsis due to aspiration pneumonia Recent admission with pneumonia, but was not back to her baseline Daughter had written a letter to the care home that in the event of deterioration, for patient not to be sent into hospital(Community DNAR form)

4. Case 2 Admitted to hospital in 25/12/13 Decreased oral intake for 2 days and cough with expectoration Lethargic O/E GCS 7 (E2, M4, V1) Chest clear No obvious signs of sepsis

5. Case 2 Bloods indicated dehydration and potassium was elevated Other investigations-Normal My feeling Patient was dying Plan Discuss with family and keep patient comfortable Treat hyperkalemia and start IV fluids awaiting discussion with family

6. Case 2 Daughter arrived on boxing day morning. Wanted mother kept comfortable Patient started on LCP Went back to NH for end of life care and died in NH

7. Case 2 Spoke with nurse at care home Issues No plan in place for end of life care Aspiration pneumonia is usually preceded by a bout of choking with copious secretions. This distresses both patient and nursing home staff. Concerned that she will choke to death.