1. End of Life Issues
Eshiet I.

2. Withholding and Withdrawal of Medical Treatment
Every competent adult has the right to determine what treatment he/ she does or does not wish to receive. There is no ethical or legal distinction between withholding and withdrawing medical treatment.

3. Advance directives
Many patients are afraid that they would lose control over their care if their decision- making capacity is impaired. Advance directives are statements by competent patients that indicate who should act as surrogate or what interventions they would accept or refuse in case they should lose their decision- making capacity.

4. Importance of Advance Directives
Advanced directives show respect for patients by allowing their preferences and values to guide care even when they can no longer make informed decisions. In addition, it might relieve stress on family members who must make decisions for them. Many patients also want to provide substantive directives about their goals and values or about what life sustaining interventions they would want or not want.

5. Standards Used when patients lack decision making capacity
Advance directives
Oral statements to family members or friends
Oral statements to physicians
Written documents- Health care proxy or living wills
Substituted judgments
Best interest of the patient

6. DNR ORDERS
A “ Do Not Resuscitate” ( DNR) order means if the patient dies, the doctor withholds CPR. This doesn’t imply that the patient is preterminal. Other treatments, such as antibiotics, transfusions, and even intensive care are administered.

7. Case 1
You have a patient with severe multiple sclerosis that is advanced and progressive who now develops renal failure secondary to diabetes. The patient is alert and has elected to put the DNR order in place at her own discretion. The patient’s potassium level is now markedly elevated at 8mEq/l. what is the appropriate management?
Dialysis can’t be done because of the DNR order
You can do the dialysis if the DNR is reversed for the procedure
Go ahead with the dialysis; ignore the DNR order
Discuss DNR status with the family

8. Case 2
A 55- year old man has been admitted to the hospital for worsening of his mental status, poor nutrition and inability to eat when fed. The patient has Creutzfeld – Jacob disease and will not likely improve. Over the last several months the patient has told you repeatedly that he does not want to be “kept alive as a vegetable” with artificial nutrition and hydration by any method. The health – care proxy form specifically states there is to be “ no placement of a nasogastic or gastric tube for enteral feeding”. The health- care proxy agent is a nurse and insists that you have a jejunostomy tube placed. What should you do?
Place the J- tube
Tell the proxy to get a court order for the J tube
Do not place any form of tube for artificial nutrition or hydration
Transfer the patient to another physician who feels comfortable placing the J- tube

9. Case 3
A 70-year-old man with terminal pancreatic cancer is admitted to the hospital because of severe shortness of breath. He has no documented advance care plans. His three children tell the physician that they want everything possible to be done for their father, including cardiopulmonary resuscitation (CPR) and intubation, if necessary. The patient is cachetic and unaware of his surroundings. Which of the following initial responses by the physician is most appropriate? (A) "I hear you, and I understand how difficult it must be for you to see your father ill. Let's talk more about the options." (B) "I know that you are distressed about your father's illness, but you must accept that he will die soon."

10. (C) "I want you to reconsider your decision about CPR and intubation
(C) "I want you to reconsider your decision about CPR and intubation. Your father's prognosis is very poor." (D) "Relatives in this type of situation feel distressed, and they want to prolong the life of their loved one unnecessarily." (E) "You are just prolonging the inevitable. Your father is going to die.”

11. You are caring for a 65-year-old African American man in the inpatient wards of a busy community hospital. He was admitted for shortness of breath and initially diagnosed with a COPD exacerbation. A routine chest X-ray revealed a large hilar mass and CT scan confirmed the presence of a four centimeter mass in the right hilum. While consenting the patient for a bronchoscopy and biopsy, the patient tells you, “Doc, please don’t tell me what they find because if it is cancer, I don’t want to know”. Which of the following is the most appropriate reply to this patient’s request? e

12. A. I will need to get a psychiatric evaluation first to decide if you are competent to make decisions
B. you are competent to make all health care decisions, so I am ethically and legally obligated to share your health information with you
C. tell me more about your depression
D. if you do not want to know the results, then I will be unable to do the procedure because there is no point in it
E. do you have any family members who you would like to make further decisions about your health care?