•Group 6

• Thapa magar
• Tiongson
• Trivedi
• Umil
• Uwimbabazi
• Velasco
• Wapano
• Yarkareddy
• Gonzales, A
• Vidalion odessa
• Juan
• The public guardian has just been granted healthcare decision making power for Ms.
Long, a 78 year-old woman with severe dementia, diabetes with impaired vision,
and poor kidney function, recent recurrent pneumonia, and prior strokes. You
are seeing her for the first time in a skilled nursing facility. She was transferred there
yesterday following a four-month hospitalization.

• When you arrive at the skilled nursing facility to see Ms. Long, she looks very thin,
and the nurse tells you that there is a large necrotic pressure sore on her sacrum.
The aides are repositioning her so that the speech therapist can do her evaluation.
There is an IV running fluids in the patient's left arm, and her right arm lies limp on
the bed. Some of the time she seems to look at a face and track movements, but
sometimes not. She does not give any answers to simple questions, either
verbally or with nods or shaking her head, and does not consistently look at the
person who is talking to her. She does not give any social smile in response to the
speech therapist's attempts to engage her. You notice that the patient grimaces when
she's moved, and cries in apparent pain when she is rolled on her back. She opens
her mouth when offered a straw but does not suck on the straw. She takes a small
amount of ice cream that is offered by spoon, but after two more tries by the speech
therapist she pushes it away and slaps using her left hand.
• Yes, she is terminally ill.
• Terminal illness is an incurable disease that cannot be adequately
treated and is reasonably expected to result in the death of the
patient within a short period of time.
• -Dementia
• -Diabetes with impaired vision
• -Poor kidney function
• -Recently recurrent Pneumonia
• -Prior stroke
• -Hospitalized for long period
• -Large necrotic pressure sore on her sacrum
• -Unresponsive
  pain medication for her necrotic
Be able to provide best comfort
pressure sore on her sacrum
for the patient  Proper wound cleaning and
To improve the quality of lifedressing of the necrotic
pressure to prevent further
To do no harm complications
To provide everything  forConstant
the repositioning of the
benefit of the patient patient to prevent further bead
sores
 to spend quality time with them feeding because she
 NGT
at least make them happy in the be fed normally
cannot
remaining days of their lives
 Open IV lines for infusion to
prevent dehydration
• Artificial nutrition and hydration (ANH) is the provision of
nutrition and fluids by any method other than normal eating and
drinking.
• Parenteral
• Large central vein- Total Parenteral Nutrition

• Enteral
• Stomach (Gastric tube)
• Percutaneous Endoscopic Gastrostomy
• Intestines
• Jejunostomy feeding tube
For ANH
• Basic human need
• Prevents confusion, agitation,
neuromuscular irritability, prevents
OIN, relives thirst
• prolong life, but not to a
meaningful degree
• Maintains bond with patient
Against ANH
• Aspiration
• Procedural complications such as
bleeding, infection, pain,
perforation, tube displacement,
bowel obstruction (enteral
feeding), and death
• Loss of pleasure from eating or
drinking Decreased human
contact/socialization
• Increased risk of physical restraints
• Fluid overload: edema (especially
in patients with cardiac failure,
increased respiratory secretions)
• Diarrhea and nausea/vomiting,
electrolyte imbalances
• Giving artificial hydration was already being done to the
patient.
• Choose an appropriate IV solution for the case plays a vital
role, especially if the patient can no longer do simple day to
day activities.
• Ideal IV solutions include D5 water and other glucose containing
solutions.
• Consider giving TPN.
• Obtain an informed consent
before performing any
management will be required
for the said form of
management.
• Since the patient can no longer
be considere coherent, relatives
of the patient will be informed
of the patient’s
• If however the patient has no
relatives I think the principle of
Beneficence and Non
maleficence should be applied
• Cardiopulmonary resuscitation (CPR)
• Emergency procedures consisting of manual respiration and chest
compressions performed in an attempt to restore the respiratory and
circulatory function of a patient who has gone into a cardiac or
respiratory arrest.

• DNAR/DNR Order
• Instructions of a physician not to initiate CPR in cases when a patient goes
into Cardiac or respiratory arrest. It is appropriate only in the terminally
ill patient when his underlying condition or disease is medically incurable
or irreversible or untreatable with the current available means and
technology and which condition or disease is expected to cause death.
1. The decision not to resuscitate a patient must be arrived at only after thorough
evaluation of the patients’ medical status and prognosis and with consultation, if
necessary, with various medical authorities and specialists concerned.

2. The attending physician is responsible for adequately explaining the nature and the
prognosis of the illness to the patient or his nearest next of kin in cases of incompetence
and the consequences of not instituting resuscitation efforts including withdrawal and
withholding extraordinary life support equipment to the patient.

3. The order for a DNR is made by the attending physician and should be legibly
written in the patient’s records in the own handwriting and with justification why the
order is given.

4. The rationale, explanation and discussion of the DNR order must be documented in
the patient’s record with the consent of the competent patient next of kin or who is
legally responsible for the patient if he is incompetent
5. The DNR order is a consensual decision of the physician and the competent
patient or his nearest kin in case of incompetence in the following order: spouse,
children of legal age, parent or parents, siblings, or legally appointed
guardians.
• 1a. If the patient is incompetent and has no relatives or is abandoned by
his relatives, the decision or consent must be referred to the proper
medical authorities such as the medico-legal officer, the Chairman of the
Ethics Committee or the Director of the Hospital.
• 2a. In case of pregnant patients or newborn or pediatric patients, the
decision for a DNR order must be referred to the Ethics Committee.
• 3a. A DNR order cannot be given if the patient of the next of kin
disagrees with the decision.
• 4a. In patients with medico legal questions, the decision for a DNR must be
referred to the medico legal officer of the Institution and the Ethics
Committee
6. The assistance of the hospital chaplain or appropriate religious authority
may be asked to help explain the situation or serve as witness to the discussion
or may advice the patient or next of kin regarding the often difficult decision
and render spiritual care.

7. If the medical condition of the patient improves, the DNR order must be
revoked immediately and must be transmitted to all the members of the team
and nursing staff.

8. Supportive measures and nursing care to alleviate the patient’s suffering

must not be withheld despite an on-going DNR order. A DNR order is not an
abandonment of care but a re-direction of care to that which will alleviate
suffering and ensure proper dignity.

9. Praying and other religious activities must be respected and even

encouraged. The family may seek spiritual guidance and services during the
last hours of the patient.
THANKYOU