For the third time in the last 6 months an 84-year-old man with advanced dementia is admitted to a hospital for aspiration pneumonia. He has lost 9.5 kg in the last 10 months. He has a pressure ulcer in the sacrum. He does not communicate verbally, does not ambulate and is dependent for all activities of daily living. His wife cares for him at home and does not want to place him in a nursing home. A swallowing study indicates that he chokes on all types of food consistencies. The hospital physician suggests tube feeding. The patient's "Advance Living Will" states that his wife is the representative decision maker regarding his medical care and that he does not want extraordinary measures to prolong his life including artificial nutrition. Which of the following is the most appropriate recommendation for this patient:
This is perhaps the least scientific of this year's MIR questions, since its answer is based on the interpretation of a law, which is also of an autonomous nature. Probably the spirit of the examiner wants to reflect this law, in an extreme case. Let's see, starting from article 11 of Law 41 /2002, of November 14 (1), basic law regulating patient autonomy and the rights and obligations regarding information and clinical documentation (B.O.E. No. 274, of November 15) of a national nature, in Castilla-La Mancha there is Law 6/2005, of July 7 (2), of Castilla-La Mancha, on the Declaration of Advance Directives in matters of one's own health. (D.O.C.M. No. 141, of July 15) and Decree 15/2006, of February 21 (3), of the Registry of Advance Directives of Castilla-La Mancha (D.O.C.M. No. 42, of February 24). In the summary published by the JCCM (4) it says: "The declaration of advance directives (also known as advance directives or living will) is the written manifestation of a capable person who, acting freely, expresses the instructions to be taken into account regarding the health care he/she wishes to receive in situations that prevent him/her from communicating his/her will personally, or regarding the destination of his/her body or organs once death has occurred. In our declaration of advance directives, we can refer to: 1. The expression of personal values, in order to help in the interpretation of the document itself and to guide physicians in making clinical decisions. 2. Instructions about the care and treatment related to our health that we may or may not wish to receive. 3. We may appoint a representative to act as an interlocutor with the responsible physician or health care team to ensure that the instructions contained in the declaration are carried out. 4. We may also include our decision regarding organ donation. In these cases, the authorization of the family will not be required for the removal or use of the donated organs". It thus seems clear that the intended response is 5.
Place an indwelling SNG and discharge to a skilled nursing home.
Place a mid-term NGUS and discharge to a nursing home with specialized care until bedsores heal.
Discharge to a nursing home with specialized care until pressure ulcers heal.
Place a gastrostomy tube and discharge home.
Discharge home with palliative care from the health area.