The correct answer is 1 since the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament, the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law.

The [HIDDEN] since the patient is in a situation of psychotic depression and is not able to decide for his life and it does not seem that the patient has filled in the last will and testament, the most convenient thing to do is to present the case to the ethics committee of the center to make a decision on the matter in accordance with the law.

A 75 a man is admitted to the hospital because he refuses to eat and has lost 30% of his weight. He has a history of multiple sclerosis which has worsened in recent months. His only family member who was his sister died 3 months ago and since then he has deteriorated. He has become incontinent, has stopped eating and participating in social events. He is suffering from psychotic depression. He is physically able to eat. Psychotropic medication is started and discontinued due to adverse events. If his nutritional status improves it is possible to resume his medications. He refuses intravenous fluids and then accepts them but the IV is started a few hours later. An alternative is to perform a percutaneous endoscopic gastrostomy (PEG) and discharge him to his residence. Which of the following is the most appropriate course of action for this patient?

Ask the hospital ethics committee to help determine the decision that is in the best interest of the patient.

Assess whether the residence will take the patient if PEG is not performed.

Enrolling the patient in terminal palliative care.

The Case.

Mr. Hope is a 40-year-old man who has resided at a long-term care facility for the past 10 years. The resident was originally admitted to the nursing home for his inability to care for himself secondary to advanced AIDS and complications from progressive multifocal leukoencephalopathy (PML). When he initially arrived at the nursing home, Mr. Hope was able to smile and appeared to respond to some of the staff's requests. Now, he responds by wincing when told that procedures are being performed and especially when he is told that he has to go back to the hospital. He is extremely contracted, with his arms wedded to his chest in a crossed fashion, as though he is protecting himself from blows. Mr. Hope's family consists of a partner, his parents, and one sibling. Numerous conversations have been had with the family, and according to the facility staff, "they persist in continuing aggressive measures with the hope that the patient will wake up and walk out of the facility." What had been frequent visits to the local hospital ER have increased substantially in the last few months, for what appear to be new infections and pneumonia. During most visits he ultimately spends a few days in the hospital to resolve his acute issues. On his most recent return to the long-term care facility, the medical staff approached the family about Mr. Hope's code status. The family continues to insist on a full code status and that he be provided every opportunity to "live." The staff is very concerned about Mr. Hope and his welfare. Many of the nursing staff have grown attached to him over the years, and watching him deteriorate has been distressing. They see part of their role as being his advocate and supporting him in ways that his own family has not. They express very strong reservations about performing CPR on Mr. Hope because they think it will be ineffective and they will have to break his upper extremities in order to gain access to his chest for resuscitation. The staff has contacted the ethics consultation service with the request that Mr. Hope needs protection and that his own family is not making the best decisions for him.

[For terminal cancer patient inserted with four tubes to live at home--from discussion with family].

The patient was an 86-year-old man with mild dementia, and a urinary bladder catheter already inserted for benign prostata hypertrophy. At this time he had jaundice due to duodenal papillary cancer and was inserted with a percutaneous transhepatic bile drainage tube (PTBD). Additionally, due to an obstruction of his duodenum, he received a percutaneous endoscopic gastrostomy tube (PEG) for suction of gastric juice and intravenous hyperalimentation catheter (IVH) for nutrition. He always wished to return home. The medical staff and his family discussed this many times to realize his hope. We his daughter-in-law how to handle the 4 tubes. When she learned how, he went home and was on the visiting care system. But only one week after, despite his stability, his son, who was living apart got drunk and sent him back to the hospital. We tried to persuade them, including all family members living apart. At last he could return home again, and one week after died quietly at home. We learn from this case that it is important and very difficult for a family to accept a terminal cancer patient at home. It is necessary to advice them from two stand-points, the medical techniques and the mental aspects.

Navigating Medical Care for a Young Adult with Developmental Disability.

Sam is a 20-year-old young man with intermittent gastritis, autism spectrum disorder, and intellectual disability who was admitted to the hospital because of nutritional concerns. His parents have legal guardianship and report that he has had increasing frequency of refusal to eat, resulting in a 15-pound weight loss over the past 3 months. On admission, a multidisciplinary team including specialists in gastroenterology, nutrition, feeding (behavioral and mechanical), psychiatry, palliative care, and social work was engaged to develop an evaluation and care plan. Sam's nutritional assessment was significant for severe malnutrition. An upper endoscopy was performed and was without abnormalities, including signs of significant gastritis.An upper endoscopy was performed and was without abnormalities, including signs of significant gastritis.A carefully obtained history found that Sam does not have a primary care physician. He was recently hospitalized at another facility because of his weight loss and nutritional concerns but was discharged against medical advice because of parental dissatisfaction with his care. His mother shared that she has tried many strategies to encourage Sam to eat including pushing spoons of food into his mouth, syringe feeding, and verbally pleading with Sam to take a bite, but all of these have been without success.Because of concerns that persistent attempts to verbally and physically coerce Sam to eat may be contributing to his aversion to food/eating, the feeding team provided Sam's parents with education and coaching for utilization of behavioral cues to determine when Sam wanted to eat. Despite parents expressing their understanding of the importance of avoiding physical attempts to "make" Sam eat and the team palliative care physician meeting with Sam's parents to elicit their goals for Sam's care, his nurses reported observing several instances of Sam's mother tapping a loaded spoon on his lips. Because of minimal oral intake, a nasogastric tube was placed for provision of hydration and nutrition. Sam's parents consented to the use of soft restraints and the presence of a bedside patient care assistant because of Sam becoming agitated and pulling at the tube.After 10 days of hospitalization, Sam was taking about 50% of his goal intake by mouth. Unfortunately, Sam removed his NG tube, and his parents refused to allow the tube to be replaced. Sam's parents then discharged him against medical advice, stating that they believed he would recover better at home. What are important considerations in caring for patients like Sam in the hospital setting and beyond?

No Judge Required: M (By Her Litigation Friend, MRS B) v A Hospital; M (Withdrawal of Treatment: Need For Proceedings) (2017) EWCOP 19.

The two titles of the judgment on which this commentary is based reflect the fact that its scope was wider than resolving the legal matter at issue between two parties. It records the reasons for Jackson J's decision on a set of facts, it clarifies whether legal proceedings were necessary and the form that they should take, and it explains why the Court of Protection appointed a patient's mother as her litigation friend. The case arose from a request for a declaration that it would be lawful to withdraw clinically assisted nutrition and hydration from a woman with Huntingdon's disease who had been in a minimally conscious state for about one year. The application for withdrawal was supported by everyone whose evidence was heard. Jackson J stated that, in such cases, clinicians would be protected by the Mental Capacity Act 2005, and that court proceedings were therefore unnecessary. He explained that, provided that certain criteria are met, and the circumstances are appropriate, a court may appoint a family member or friend-rather than the Official Solicitor-to act as a litigation friend. This commentary explores the implications of this judgment in the context of very recent clinical developments.

Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.

Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he "screams, cries, and thrashes and can stay up for over an hour." His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing "tolerance" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index >99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?

InternalMed_Harrison

End-of-Life Decisions Unfortunately, a smooth transition in treatment goals from curative to palliative may not be possible in all cases because of the occurrence of serious treatment-related complications or rapid disease progression. Vigorous and invasive medical support for a reversible disease or treatment complication is assumed to be justified. However, if the reversibility of the condition is in doubt, 475 the patient’s wishes determine the level of medical care. These wishes should be elicited before the terminal phase of illness and reviewed periodically. Information about advance directives can be obtained from the American Association of Retired Persons, 601 E Street, NW, Washington, DC 20049, 202-434-2277, or Choice in Dying, 250 West 57th Street, New York, NY 10107, 212-366-5540. Some states allow physicians to assist patients who choose to end their lives. This subject is challenging from an ethical and a medical point of view. Discussions of end-of-life decisions should

[A case of serious aspiration pneumonia associated with multiple cerebral infarctions and Alzheimer's disease followed by hospital and home care service team].

A 81-year-old man, who had been diagnosed in multiple cerebral infarction and Alzheimer's disease, was followed up in his local clinic since 1997. He had been bedridden before admission, but could eat. He was admitted with severe aspiration pneumonia in December 1999. Since severe dementia and dysphagia were noted after admission, he was examined to find out whether or not he could swallow while the treatment of his pneumonia was conducted at the same time. The water swallowing test indicated a risk of aspiration, thus, percutaneous endoscopic gastrostomy was performed on January 26, 2000 after the completion of the treatment for pneumonia. Although the patient's condition was complicated by aspiration pneumonia, enteral feeding through the gastric fistula gradually became successful, and he was discharged in June 2000. His family physician followed him up by visiting at home to examine and observe his general physical condition including consciousness, vital signs, skin and respiration, while taking measures in cooperation with the local health care visiting nurse. The patient, thereafter, was repeatedly admitted and discharged because of exacerbation and remission of symptoms, including coughing, sputum and fever, probably caused by aspiration pneumonia. When he was admitted in December 2001, which was his sixth admission, since there were troubles with the infusion tube and frequent gastroesophageal reflux, the gastric fistula management was judged to be a great burden on the patient. In January 2002, the gastrostomy tube was removed and the patients, whose alimentation was managed using intra-venous hyperalimentation (IVH), was discharged. Besides periodic visits by his family physician, a 24-hour house visit system was introduced to control his IVH and deal with his family members' anxiety. His general condition, thereafter, has not markedly changed. The patient has continuously received medical treatment for 14 months after being discharged and his condition is stable.

Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y.

In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.

Interoception in Practice: The Gut-Brain Connection.

Tony is a five and a half-year-old boy who has been a patient in your primary care practice since he was adopted at birth. He has been treated by a child and adolescent psychiatrist for behavioral concerns starting at age 3 years and has been diagnosed with autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD) combined type, anxiety disorder, and insomnia. He presents today with complaints of repeated emesis and refusal to eat or drink over the past 2 weeks and is now dehydrated. Tony was born at 30 weeks' gestational age by vaginal delivery with a birth weight of 4lbs 15oz and was described as minimally responsive at birth. There was known prenatal exposure to tobacco and methamphetamine and inadequate prenatal care. The maternal history is notable for a reported diagnosis of bipolar affective disorder, prostitution, and being unhoused at the time of delivery. Tony received antibiotics after delivery for presumed newborn infections. As an infant, he had kidney reflux, low serum ferritin, insomnia, and failure to thrive. Regarding developmental milestones, Tony was sitting up at 7 months, walking at 14 months, talking at 18 months, and speaking in full sentences by 24 months. When he presented to the psychiatric service at age 3 years, behavioral problems included irritability with destructive rages, excessive fears, separation anxiety, hyperactivity, and impulsivity with a lack of awareness of danger to the extent that he required a safety harness when in public and security locks in the home because of repeated elopements. Tony also had at the time of his initial presentation significant defiance, extreme tantrums, violent aggressive outbursts, cognitive rigidity, repetitive behaviors, resistance to change, frequent nondirected vocalizations, and self-injurious behaviors including slapping himself on the head and biting of his hands and feet. Review of systems includes complaints of frequent abdominal and neck pain, persistent insomnia, night terrors, restrictive eating habits with poor weight gain, and reduced sensitivity to pain. Treatment history included gabapentin and subsequently divalproex for seizure-like episodes (despite negative EEG) described as frequent staring spells with repetitive biting of his lips. Psychotropic medications were risperidone for irritability associated with autism and clonidine extended release for ADHD. He also took melatonin for sleep. During his well-child check at the age of 5 years, Tony is making good progress from a developmental standpoint, has age-appropriate expressive and receptive language skills, is fluent in both English and Spanish, is able to recite the alphabet, counts to 20, has learned to swim, and is demonstrating interest in planets and astrology. He is reported to have a secure attachment to his adoptive parents and is described as emotionally sensitive, caring, kind, considerate, and empathetic. He has good eye contact and can read facial expressions. He is affectionate and protective of his infant sibling, his biological sister, who is also adopted by his parents and now living in the home. Tony made an excellent adjustment to the start of kindergarten and up until this point was responding positively to his psychotropic medication regimen. But then at age five and a half, Tony experienced sudden and unexplained behavioral worsening, which was followed by the onset of recurrent vomiting and refusal to eat or drink. Comprehensive medical workup including upper endoscopy and biopsy resulted in a diagnosis of eosinophilic esophagitis (EoE). What would be your next step?

Causes and consequences of delays in treatment-withdrawal from PVS patients: a case study of <i>Cumbria NHS Clinical Commissioning Group v Miss S and Ors</i> [2016] EWCOP 32.

Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their family believes the patient would not want it and despite the fact that no court in the UK has ever found in favour of continuing such treatment for a patient with a confirmed PVS diagnosis. The first half of this article presents a close analysis of the recent case of <iCumbria NHS Clinical Commissioning Group v Miss S and Ors</i [2016] EWCOP 32. It examines the causes of delay in bringing this case to court and reaching a final judgment. It draws not only on the published judgment, but also on the two authors' involvement in supporting the family (before, during and subsequent to the court hearings) as a result of their academic and policy-related work in this area. This includes conversations with the family and with members of the clinical and legal teams, and observations in court. The second part of the article draws out the ethical and practical implications of the findings for theory and policy and suggests ways forward in relation to (a) the provision and inspection of care for these patients; (b) legal practice in relation to 'best interests' and (c) the perceived requirement under English law for a court application before life-prolonging treatment can be withdrawn from PVS patients-even in the absence of any 'in principle' opposition.

[Reviewing the so-called ″Living Will″].

Cases like those of Terry Schiavo or Eluana Englaro have given rise to a lot of discussions at all levels. What both of them have in common is that, beyond the reasons given for terminating their lives and the methods used to achieve it, their destiny was not decided by them. This has resulted in a lot of heated debates in the public sphere as well as in the juridical, political, medical and speculative-ethical fields. Many people have been led to ask themselves: ″Wouldn't a better solution have been found if the desire of both persons had been known without any shadow of doubt, in the case that they had foreseen the situation in which they eventually found themselves in?″. The concept of the so-called Living Will appears to be a good solution for such cases. However, in the years in which attempts have been made to introduce this into practice, important ethical questions regarding end-of-life situations have come up: Can everything in my life, including when and how I die, be part of a legacy? Is a person who enjoys good health in a position to autonomously determine how he would like to be treated if, in an uncertain future, he ends up in a situation where he is incapable of communicating his wishes? Is the ordinary citizen capable of domineering the multiplicity of treatments, diagnosis and prognosis which medical science has to offer? Is it the same thing to forego a complicated treatment as to renounce artificial feeding and hydration? This article examines all these arguments, offering at the same time the case for and the case against the so-called Living Will.

Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder.

Thomas is a 12-year-old boy with autism spectrum disorder who presents to his primary care clinician with symptoms of worsening mood in the last 3 months. On review of his last school testing, his cognitive abilities are found to be within the average range, with a relative vulnerability with his processing speed. He can speak in sentences to communicate and answer questions, but he rarely picks up on conversational bids. He has had difficulties developing friendships and often prefers to play by himself.Thomas has a long history of some features of anxiety and depression for which it was recommended that he establish care with a therapist, but his family has had a hard time finding a provider for him. At this visit, the mother reports that for the past several months he has been more anxious, sad, and easily overwhelmed. He seems irritable at home and school and cries often. His family has been advocating for him to receive increased school supports, as school is a source of anxiety for him, but there are no recent changes in school services. There is a family history of both anxiety and depression. Given his worsening mood functioning, Thomas was started on selective serotonin reuptake inhibitor (SSRI) medication in addition to again recommending a therapist. Weekly phone call check-ins and an in-person clinic visit in 1 month are planned.About 1 month after starting the SSRI medication, he is still not showing any improvement in mood functioning, and his family reports he seems more "sluggish" than usual. There are no side effects reported with the medication, and the dose is increased to see whether it will help. However, about 2 weeks later, he is seen again in the clinic because there are increasing concerns. He continues to be "sluggish." During the clinic visit, he lies down on the examination table, sometimes holding his head off the edge of the table, which he has never done before. He responds very slowly to the questions and often says "I don't know, I don't know," almost in an automatic way. His mother reports that he is now engaging in some repetitive hand movements which he had not done previously. He is no longer able to shower independently. He is still eating and drinking adequately. What would you do next?

The weight attributed to patient values in determining best interests.

In W v M and Others (Re M) the Court of Protection considered whether withdrawal of artificial nutrition and hydration was in the best interests of a person in minimally conscious state. The Mental Capacity Act 2005 states that in determining best interests the decision-maker must consider, so far as is reasonably ascertainable, the patient's wishes, feelings, beliefs and values. Baker J. indicated that a high level of specificity is required in order to attribute significant weight to these factors. It is preservation of life which carries substantial weight in the best interests' balance sheet. Could the (prior) values of a patient ever meet the probative standard necessary to offset the weight accorded to preservation of life? Rather than referencing the patient's values to specific circumstances and treatments they could be more effectively considered as part of the patient narrative, how the patient would want her life story to continue/cease.

The <i>Briggs</i>ian Heresy? Should Previously Expressed Wishes Determine Best Interests in Decisions Relating to Withdrawal of Clinically-Assisted Nutrition and Hydration?

This paper examines the Court of Protection decision in <iBriggs v Briggs</i. It considers whether the approach of the Court, which gave effective decisive weight to a patient's previously expressed wishes about whether he should be kept alive in a minimally conscious state, is a proper application of the 'best interests' test under the Mental Capacity Act 2005. It assesses whether the <iBriggs</i approach is effectively applying a 'substituted judgement' test and considers the difficulties in ascertaining what a person's actual wishes are.

[The life of Dr. John William Heron, the second superintendent of Chejungwon].

The purpose of this paper is to overview the life of John W. Heron, M. D. who was the first appointed medical missionary to Korea by the Presbyterian Church USA. Although he was a competent doctor as well as a devoted missionary, he is not well-known yet, because he died early after 5 years' service in Korea. Dr. Heron was born in Derbyshire, England on June 15, 1856. His father, Rev. E. S. Heron, was a Scotch Minister of Congregational Church. His family emigrated to America in 1870 when he was fourteen years old and settled in Knoxville, Tennessee. In 1881, he was admitted to the University of Tennessee Medical School and graduated with highest honors in 1883. After training in New York University Hospital, he refused the offer of professorship from the University of Tennessee to become a medical missionary to Korea. He arrived in Seoul on June 21, 1885 and began to work in Royal Government Hospital, Chejungwon, the predecessor of Severance Hospital. In 1887, he became the superintendent of the Hospital following Dr. Horace N. Allen. He also worked for the Royal family and sometimes traveled to the rural areas to care for the patients. He started Chejungwon Church which later became Namdaemoon Presbyterian Church. In 1887, Dr. Heron worked as a member of the Bible translation committee and in 1889, he was elected as the chairman of the Public Committee of the Presbyterian Churches. In 1890, he established 'The Korean Religious Tract Society (Chosunsyungkyoseohoi) with Underwood and Ohlinger. The society published and replenished Christian books, periodical magazines and booklets. In the Summer of 1890, Dr. Heron did his best to take care of the sick suffering from an epidemic dysentery and himself got infected because of the terrible overwork. He passed away on July 26th, 1890. On his deathbed, he told his soldier and native friends around him as follow: "Jesus loves you. He gave His life for you. Stand by Him!" The martyrdom of Dr. Heron should be remembered in the Korean history of mission, because he was the first victim among the foreign missionaries who had lived and worked in Seoul for Korean mission. Dr. Heron's mind of love, service and devotion should be remembered by the medical doctors working today in caring for the patients suffering from physical and spiritual illnesses.

Rehydration in palliative and terminal care: if not--why not?

Patients who are in the last few days of life are often too frail to take oral fluids and nutrition. This may be due entirely to the natural history of their disease, although the use of sedative drugs for symptom relief may contribute to a reduced level of consciousness and thus a reduced oral intake. Rehydration with intravenous (i.v.) fluids is the usual response in acute care settings, whereas the hospice movement has often argued against this approach. The issues are complex and involve not only physical, psychological and social concerns, but also ethical dilemmas. A review of the literature gives conflicting reports of the physical discomfort that may be attributed to dehydration in dying patients. There are many confounding variables, including the concomitant use of antisecretory drugs, mouth breathing and oral infection. It remains unproven whether i.v. fluids offer symptomatic relief in this situation. Hospice doctors are concerned that the use of i.v. fluids gives confusing messages to relatives about the role of medical intervention at this stage in a patient's illness. A drip may cause a physical barrier between a patient and their loved one at this important time. The use of other methods of fluid replacement are discussed. In the absence of definitive research in this area, the balance of the burdens and benefits of such treatment remains subjective. The prime goal of any treatment in terminal care should be the comfort of the patient. Decisions should be made on an individual basis, involving both patients and their carers wherever possible. Prolonging life in such circumstances is of secondary concern and i.v. fluids given in this context may be futile. The ethical dilemmas of withholding and withdrawing medical treatment in addition to those of conducting research in this area are discussed.

Delayed Presentation of DPD Deficiency in Colorectal Cancer.

Case Study  Mr. D., a 55-year-old male, presented to the medical oncology service with a diagnosis of stage III adenocarcinoma of the sigmoid colon. He presented 7 weeks post sigmoid colectomy with lymph node resection and was initiated on adjuvant chemotherapy with CAPOX (capecitabine [Xeloda] and oxaliplatin [Eloxatin]). Standard dosing was used: oxaliplatin at 130 mg/m(2) on day 1 and capecitabine at approximately 2,000 mg/m(2)/day (rounded to the nearest 500-mg tablet size) for 14 days on and 7 days off (1 cycle = 21 days). A capped body surface area of 2.4 m2 was used, due to the patient's body habitus. Adverse Effects  Mr. D. did not report any complications of therapy during cycle 1, days 1-7, other than grade 1 diarrhea, which was amenable to diphenoxylate/atropine when taken. The next week, he reported significant malaise and fatigue associated with persistent diarrhea occurring every 30 minutes for 5 days. Mr. D. was instructed to go to the emergency room for an immediate evaluation, but he refused. Mr. D. presented to the clinic in poor condition on day 14 of cycle 1. His diarrhea had increased to grade 3 and was not controlled with either loperamide or diphenoxylate/atropine, though he was not taking his medications as directed. He had been instructed to take two 2-mg loperamide tablets after the first loose stool, followed by 1 tablet of diphenoxylate/atropine 2 hours later. He could then alternate this with loperamide every 2 hours as needed, not to exceed 8 tablets of loperamide per day. Instead, he had taken 2 tablets of loperamide after the first loose stool, but either waited 6 hours to take 1 tablet of diphenoxylate/atropine or otherwise chose not to alternate the medications at all despite continued diarrhea, depending on the day. Mr. D.'s timing in taking his supportive medications was inconsistent, and his explanations of this timing were not exact. He also reported persistent grade 3 nausea with vomiting for 5 days, which did not improve with ondansetron and prochlorperazine, though he again did not take these consistently. He was advised to alternate ondansetron and prochlorperazine every 4 hours as needed, but only took one or the other medication approximately 3 times per day. According to Mr. D., his adverse effects initially began on day 9 of cycle 1. He had lost approximately 14 kg (31 lb) during cycle 1. Clinically, he was found to have grade 2 mucositis and grade 1 hand-foot syndrome. At the time of this visit, his absolute neutrophil count was 3,000/ìL, his hemoglobin was 14.4 g/dL, his hematocrit 42.2%, and his platelet count was 139,000/ìL. His kidney function was within the normal range. Mr. D. refused hospitalization despite the primary team's recommendation. He also refused to undergo stool sampling for Clostridium difficile. He was given IV fluids along with adjustments in supportive medications, including a prescription for 10% tincture of opium. He was instructed to use 0.6 mL every 6 hours in addition to alternating loperamide with diphenoxylate/atropine as noted previously. He was advised to rinse his mouth with a baking soda solution for relief of his grade 1 mucositis, and alternation of antiemetics every 4 hours was reiterated. He was to return prior to initiation of cycle 2 for further evaluation. Worsening Symptoms  The next day, Mr. D.'s wife called the clinic to report that her husband's diarrhea continued despite the use of tincture of opium and that it was associated with hematochezia. He was also experiencing a worsening of his mucositis, with an associated swelling of the tongue. He was instructed to present to the emergency center, which he did on day 16 of cycle 1. By then, he was found to be febrile at 39.5°C. He was tachycardic, with a heart rate of 126, and he was experiencing significant abdominal pain associated with the diarrhea. The mucositis was worsening, with new odynophagia. At this time, Mr. D.'s absolute neutrophil count had dropped dramatically to 160/ìL, his hemoglobin was 13.1 g/dL, his hematocrit was 39.2%, and his platelet count was 68,000/ìL. He was admitted to the inpatient service and started on empiric antibiotics. His blood cultures remained negative during hospitalization, but stool cultures were positive for C. difficile. His antimicrobial regimen was deescalated to oral vancomycin once his stool volume decreased. He was treated with an institutional compounded mouthwash of diphenhydramine, aluminum/magnesium hydroxide, and viscous lidocaine for the mucositis, which also slowly improved. He was given a dose of growth factor. Neutropenia eventually resolved, with an absolute neutrophil count of 4,820/ìL on the day of discharge. He was discharged 26 days after initiating cycle 1, at which time his myelosuppression and mucositis were also resolved. Throughout his course, he did not report any neurotoxicity. DPD Testing  Due to his severe symptoms of neutropenia, mucositis, and diarrhea, Mr. D. was tested for dihydropyrimidine dehydrogenase (DPD) deficiency. Testing confirmed a heterozygous IVS14+IG>A mutation. For this reason, all further adjuvant therapy was withheld, and he was followed on clinical surveillance only.

Ethical dilemmas in hospice and palliative care.

In order to understand some of the ethical dilemmas that face hospice programs in the United States, one must understand the Medicare Hospice Benefit, which is the model by which hospice programs provide palliative care to terminally ill patients in the United States. Unlike palliative care programs outside the United States, patients must have a prognosis of 6 months or less to receive hospice care under the Medicare Hospice Benefit. Care is reimbursed on a per diem basis, and inpatient care is restricted to pain and symptom management that cannot be managed in another setting. Ethical dilemmas that face physicians referring patients to hospice programs include the ability of clinicians to predict accurately a patient prognosis of 6 months or less, and to what extent hospice programs and clinicians are obligated to provide patients with full information about their illness, as the Medicare Hospice Benefit requires that patients sign an informed consent in order to elect the hospice benefit. There are ethical dilemmas that affect day-to-day patient management in palliative care programs including physician concern over the use of morphine because of possible respiratory depression in the advanced cancer patient, the question of providing enteral or parenteral nutritional support to patients who refuse to eat near the end of life, and the question of providing parenteral fluids to patients who are unable to take fluids during the terminal phases of illness. A final ethical dilemma concerns the methodology for quality of life research in palliative care. By following current research dogma, and only considering patient-generated data as valid, the patient population that most needs to be studied is excluded. A new methodology specifically for palliative care research is needed to provide information on the patients who are cognitively or physically impaired and unable to provide input regarding their needs near the end of life.

Community powers under the Mental Health Act: care or control?

District Nursing Sister Janet Jones had been visiting a young patient, Peter James, 20, at his bedsit on a weekly basis to assist him with the management of his diabetes. However some 6 months ago Peter stopped eating and began refusing to take his insulin because he believed that they had been contaminated by alien dust. Sister Jones and the GP also noticed that Peter was drinking considerable quantities of alcohol and there were reports of him engaging in bizarre sexual rituals. Concern about Peter's mental health and refusal of treatment resulted in him being detained under the Mental Health Act 1983. Sister Jones has now received a request from the mental health unit to visit Peter at his home during a period of leave he has been granted by his responsible medical officer (RMO) and to continue visiting as part of his aftercare arrangements when he is discharged. Sister Jones wonders if the mental health team will be able to manage Peter in the community given his previous reluctance to accept treatment and how Peter will afford the aftercare package of home care support and meals on wheels provided by the local authority.

An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal.

In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.

Who rules the roost?

Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?

Dealing with conflict in caring for the seriously ill: "it was just out of the question".

Physicians often assume that conflict is undesirable and destructive, yet conflict handled well can be productive, and the clarity that results can lead to clearer decision making and greater family, patient, and clinician satisfaction. We review the course of Mrs B, an 84-year-old woman with advanced dementia and an advance directive stating no artificial hydration or nutrition. Over the course of her illness, her family and physicians had conflicting opinions about the use of short-term tube feeding and intravenous hydration in her care. We describe the conflicts that arose between her physicians and family and a typology of conflicts common in care of patients who are seriously ill (family vs team, team member vs team member). Drawing from the business, psychology, and mediation literature, we describe useful communication tools and common pitfalls. We outline a step-wise approach that physicians can use to deal with conflicts and the use of treatment trials as a strategy to address conflicts about the use of life-sustaining medical interventions.

A toddler with hair fascination.

Joseph is a 24-months old boy referred by his pediatrician because of an "obsession" with pulling and eating hair. When Joseph was 14 months old, he enjoyed touching and twirling his mother's long hair. She observed that it seemed to provide comfort to him. At 18 months, he initiated pulling out and eating his own hair, twirling his mother's hair around his thumb and then sucking on it. Currently, he searches the carpet or a hard floor and looks for hair to eat. The identical behavior is observed at daycare. Joseph's teacher commented, "He pulled hair from a girl who has the longest hair of all the children. We try to distract him from this habit, but he is not distracted for long." Less frequently, Joseph has also eaten sand, chalk, and crayons at daycare. Joseph's mother describes him as a "happy and outgoing" child who interacts with his peers and has a best friend at the daycare. There have not been recent changes or stressful events in his life. Joseph separates from his mother with ease and he sleeps comfortably through the night in his own bed. There have been no episodes of nausea, vomiting, abdominal pain, or constipation. Strands of hair are occasionally seen in the stool. Prenatal and perinatal history was unremarkable. Joseph was breast-fed for 11 months, described as an "easy" baby, achieved motor, social, and language developmental milestones at the usual time, and has been in excellent health. He lives with his mother and maternal grandparents; the biological father has never been involved in his care. At 20 months, Joseph's pediatrician suggested cutting his hair. After several haircuts, Joseph stopped pulling his own hair. However, he continued to search the floor for hair. Hemoglobin and a blood lead level were normal. Joseph appeared pleasant and friendly with normal growth parameters and facial features. He was sitting comfortably on his mother's lap, sucking on his thumb. Social interactions with his mother were appropriate and reciprocal. He warmed up quickly to the examiner and engaged in play. He spoke in two to three word sentences and responded to questions with a speech pattern that was 50% intelligible. Physical and developmental examinations were normal. At the end of the examination, Joseph searched his mother's purse and located a piece of hair. He twirled the hair around his thumb and sucked on it. Initially, he refused to remove his thumb from his mouth. With gentle persuasion, he eventually removed his thumb and agreed to throw the hair in the trash. He did not appear distressed.

[The PEG-dilemma - pleading for an ethically responsible medical treatment].

Within the 32 years of its existence our attitude towards artificial enteral nutrition via PEG-tubes has changed in a fundamental way: in our modern understanding nutrition via PEG is supportive, early, preventive, and in many cases temporary. PEG-feeding is not an alternative but a possible supplement to normal oral food intake and requires an individual medical indication as well as an ethical justification. This does not follow standardised algorithmic thinking but is decided on an individual base taking personal wishes, resources, and needs of the individual patient into account. Nutrition via PEG-tube is not a terminal basic or even symbolic treatment at the end of life. The present dilemma of the PEG is that the public discussion primarily focus one-sided on the problems of PEG-placement in multimorbid, elderly, and/or demented patients or patients in end-stage tumour diseases where indeed PEG-placement is neither medically nor ethically justified - we still place PEG-tubes to often in the wrong patients! On the other hand we still consider supportive and in many cases temporary nutrition via PEG too rare and even too late in those patients which clearly could benefit from an early, supportive, and preventive PEG-treatment on the base of our present evidence-based scientific knowledge - we still consider PEG-treatment not adequately and in most cases too late in the right patients! Placing a PEG-tube is not the second last step before death and physicians have to accept the ethically given limits of medical treatment by realizing our modern understanding of the benefits and limits of supportive artificial nutrition via PEG.

Case report: a case of intractable Meniere's disease treated with autogenic training.

Psychological stress plays an important role in the onset and course of Meniere's disease. Surgical therapy and intratympanic gentamicin treatment are options for cases that are intractable to conventional medical therapy. Psychotherapy, however, including autogenic training (AT), which can be used for general relaxation, is not widely accepted. This paper describes the successful administration of AT in a subject suffering from intractable Meniere's disease. A 51-year-old male patient has suffered from fluctuating right sensorineural hearing loss with vertigo since 1994. In May 2002, he was first admitted to our hospital due to a severe vertigo attack accompanied by right sensorineural hearing loss. Spontaneous nystagmus toward the right side was observed. Since April 2004, he has experienced vertigo spells with right-sided tinnitus a few times per month that are intractable to conventional medical therapy. After four months, tympanic tube insertion was preformed in the right tympanic membrane. Intratympanic injection of dexamethasone was ineffective. He refused Meniett therapy and intratympanic gentamicin injection. In addition to his vertigo spells, he suffered from insomnia, tinnitus, and anxiety. Tranquilizers such as benzodiazepines and antidepressants such as serotonin selective re-uptake inhibitors (SSRIs) failed to stop the vertigo and only slightly improved his insomnia. In December 2006, the patient began psychological counseling with a psychotherapist. After brief psychological counseling along with cognitive behavior therapy (CBT), he began AT. He diligently and regularly continued his AT training in his home according to a written timetable. His insomnia, tinnitus, and vertigo spells disappeared within a few weeks after only four psychotherapy sessions. In order to master the six standard formulas of AT, he underwent two more sessions. Thereafter, he underwent follow-up for 9 months with no additional treatment. He is now free from drugs, including tranquilizers, and has continued AT. No additional treatment was performed. When we examined him six and nine months later for follow-up, he was free of vertigo and insomnia. AT together with CBT can be a viable and palatable treatment option for Meniere's disease patients who are not responsive to other therapies.

Living wills, duty of care and the right to treatment.

Agnes Simon, a district nurse with 20 years' experience, has been caring for a man with motor neurone disease for the last 5 years. During this time the patient has shown remarkable tenacity but the disease has now progressed to the stage where artificial nutrition and hydration (ANH) is required. A percutaneous endoscopic gastrostomy tube has been inserted through which the patient receives food, water and medication. On her most recent visit the patient gave Agnes a signed and witnessed living will. Unusually, the living will did not indicate the patient's wishes regarding the limitation of treatment. Instead it made clear that the patient wished to continue to receive ANH up to the time of his death. He did not want the care team to withdraw this treatment without his permission, as he feared he would suffer from the indignity of slowly dying from thirst and starvation. Agnes has never seen a living will where a patient demands a right to treatment and wonders whether such a document is lawful and binding on her.

Decision making in the critically ill patient.

In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.

Brophy v New England Sinai Hospital, Inc. Brief amicus curiae, Society for the Right to Die, Inc. on behalf of appellant.

On September 11, 1986, the Supreme Judicial Court of Massachusetts, in a 4-3 decision, authorized removal of the artificial feeding tube. It held that the "substituted judgment" of an incompetent person in a persistent vegetative state to refuse artificially administered sustenance must be honored. The Court also refused to compel the hospital in this case to terminate the treatment, but permitted other hospitals to comply with the patient's wishes. We are publishing the amicus curiae brief filed by the Society for the Right to Die, Inc. in the Brophy case. Our purpose in doing this is to stimulate further discussion of the issue of the role of the patients who become incompetent, a matter of major concern to geriatric specialists. This brief has been well-prepared. It contains a legal and ethical history of considerable merit. It has not, however, been endorsed by the American Geriatrics Society (AGS). Some of the principles the AGS has endorsed can be found on its own brief filed in the Conroy case (published in the December 1984 issue of the Journal). Physicians and medical ethicists in particular may wish to consider the caveats noted by David Thomasma, PhD. in his editorial in this issue of the Journal. We invite further discussion.

Ethics Roundtable: Advance Directives, Autonomy, and Gastrostomy Placement.

CL is a 94-year-old male who is brought to the Emergency Department from an assisted living facility due to a new onset of weakness and altered mental status. He was in his usual state of moderately compensated health, requiring assistance for most activities of daily living due to medical frailty and a previous right brain CVA with residual mild left sided weakness. On the day of admission, the staff found him lethargic and disoriented. The family requested a surgical consult for percutaneous, endoscopic, gastrostomy (PEG) tube placement. A review of the patient's records showed that the patient had refused a PEG tube during his last two hospitalizations. During the last admission, the hospitalist documented that the patient repeatedly refused nutritional support stating "if it's my time, I've lived a full life. I'm ready to die and join my wife." There was no advance care plan ("living will"), but CL did sign a "Selection of Surrogate Decision-maker" form previously, assigning his nephew as primary surrogate. Under pressure from multiple family members, including the designated surrogate, the attending requested a surgical consultation. The surgical team determined that the patient did not have capacity and scheduled CL for PEG tube placement. The care team had concerns regarding the conflict between the patient's previously (and consistently) stated desires and the family's wishes; an ethics consult was requested.

End of Life Choice Act 2019

The person must confirm their request by signing and dating a prescribed form in the presence of this practitioner. The second part of the form may be signed by someone else if the person cannot write for any reason.

Multidisciplinary team approach on tracheoesophageal fistula in a patient with home ventilator.

A 68-year-old man was transferred to our tertiary hospital. Ten years ago, he received radiation therapy for tonsil cancer, and while there was no evidence of recurrence, he suffered from recurrent aspiration. We treated his aspiration pneumonia in the intensive care unit. Prior to his discharge, he received percutaneous dilatational tracheostomy (PDT) before he was transferred to a nursing hospital. Nine months later, he was readmitted owing to tracheoesophageal fistula (TEF). However, he was considered unsuitable for conservative intervention after a multidisciplinary team discussion. Esophageal stent insertion was impossible due to the high level of TEF in the esophagus. Additionally, the size of the TEF could not be covered by an endosponge and endoluminal vacuum therapy, and there was no tracheal stent that could cover his large trachea. The preceding percutaneous enteral gastrostomy (PEG) procedure was required for the primary closure operation of the esophagus; however, family's consent could not be obtained. After 1month, the patient and his family changed their minds and agreed to the procedure and we attempted to perform PEG procedure. However, we could not proceed with PEG owing to stenosis in the inlet of the esophagus. Then, the patient deteriorated clinically and died due to pneumonia with septic shock.

Are clarifications on feeding and hydration in PVS needed by Catholic authorities?

Ever since the possibility of keeping a person on advanced life support the Catholic Church has been concerned with the rights of the individual to a dignified death and the right to refuse treatment. This right has traditionally and in documents of the Church been extended to the family in the absence of specified wishes of the patient. Again, since the controversies on patients in a persistent vegetative state (PVS) have come to public knowledge, especially with the case of Terry Schiavo, and more recently, in Italy, the case of Eluana Englaro, people have been confused about the issue of what constitutes extraordinary treatment. This article focuses on the history of advanced life support and extraordinary treatment, with special reference to PVS and attempts to conclude that given the information already available decision to withdraw such care, even if in principle it may be considered ordinary, can be pursued within the same teachings and should therefore not pose problems to medical personnel once a proper legal and ethical procedure is followed. Failure to acknowledge such history and facts is indeed admitting a failure of bioethics as a futile subject.