GC045 End-of-life Care For Hospitalised Older Adults
End-of-life care for hospitalized older adults is a comprehensive, patient-centered approach focused on symptom management, comfort, dignity, and shared decision-making for elderly patients nearing death during an inpatient admission.
Lecture Map: The Big Idea
This lecture tackles one of the most important — and most frequently mishandled — areas of geriatric medicine: how to provide quality care when an older hospitalised patient is approaching death. The central thesis is that the "default" hospital approach (tube feeding, CPR, mechanical ventilation, repeated admissions) often causes more harm than good in patients who are dying. Instead, we need a structured, goal-directed approach that centres on the patient's values and comfort.
The lecture is built around a clinical vignette (Mrs. Wong) — an 85-year-old with advanced dementia who refuses food — and uses it to walk through 5 key steps of quality end-of-life (EOL) care. This is directly examinable and is listed as required reading in the AOS Geriatrics curriculum (Chapter 19: End-of-life Care) [1][2].
1. Understand the needs and preferences of patients at the end of life and their families. 2. Discuss how prognosis impacts the appropriate management of seriously ill patients. 3. Identify approaches that improve the quality of care to patients at the end of life and provide support to families. 4. Reflect on the role of medical providers in caring for dying patients in the hospital.
- SAQs: Direct EOL ethics questions appear regularly (e.g. 2019 SAQ Q12 — DNACPR scenario; 2021 minicase — life-sustaining treatment definition) [4][5].
- MCQs: AOS-style MCQs test frailty-directed management decisions (CFS 8 → comfort care vs aggressive Ix) [6].
- Minicases: Palliative care scenarios in cancer/dementia appear in minicases (e.g. 2020 minicase — metastatic cancer with pain management) [7].
Mrs. Wong: 85/F, OAH (old-age home) resident. PMHx: HT, DM, CKD, dementia, arthritis, wheelchair-bound. Two hospitalisations in the last six months for poor oral intake and progressive weight loss. This admission: stopped taking meds and refused food. [3]
This case encapsulates the "revolving door" problem: repeated crisis admissions for a patient with advanced progressive disease, where routine acute interventions (NGT, CPR, IV antibiotics) are applied without considering the patient's trajectory.
What Went Wrong
ST assessment found high aspiration risk → recommended non-oral feeding. Doctor told daughter RT feeding is "needed for nutrition and to prevent aspiration." Daughter reluctantly agreed. Mrs. Wong pulled out NGT → placed in restraints → NGT re-inserted → GI bleeding → stopped tube feeding → cardiac arrest → CPR unsuccessful → patient dies. [3]
The daughter's final response (要交代病人死因 — "must explain cause of death") illustrates how poor communication and inappropriate interventions lead to distrust, suffering, and complicated grief.
Why This Case Matters
The lecture uses Mrs. Wong to show that the doctor's framing was wrong on multiple levels: (1) stating RT "prevents aspiration" is factually incorrect in advanced dementia, (2) the alternative of careful hand feeding was never offered, (3) no prognostic discussion occurred, and (4) restraint use violated dignity. Every one of these errors is examinable.
Half of bereaved family members thought their loved ones were in moderate to severe pain 50% of the time in their last days in the hospital. [3]
High levels of depression, post-traumatic stress, and complicated grief amongst bereaved families of patients who received aggressive care (e.g. in ICU). [3]
Why this matters from first principles: When we subject dying patients to aggressive interventions, we don't just harm the patient — we traumatise the family. Bereaved family members who witness futile CPR, prolonged ICU stays, or tube-related complications develop higher rates of PTSD and pathological grief. This is a measurable, evidence-based harm that makes aggressive care in the dying patient a net negative.
The "Revolving Door" Problem
Repeated crisis admissions → patients receive "routine" acute interventions (mechanical ventilation, IV antibiotics, CPR, tube feeding, inotropes) → poor quality of life. [3]
This diagram from the lecture shows the cycle: AED → acute ward → convalescent ward → back to AED. The key insight is that the "routine" approach was designed for patients who are expected to recover, not for those approaching death.
| Cancer | COPD | CHF | |
|---|---|---|---|
| Hospitalisation days (last 6 months) | 28 | 46 | 40 |
| Deaths in ICU | 0.3% | 2.1% | 2.3% |
| Invasive ventilation | 0% | 10% | 14% |
| Non-invasive ventilation | 1% | 46% | 13% |
| CPR | 4% | 15% | 21% |
Key exam point: Cancer patients receive the least aggressive EOL care — likely because oncologists are accustomed to recognising terminal trajectories. COPD and CHF patients receive much more aggressive interventions (CPR in 15–21%) because their trajectories are less predictable (see disease trajectories below).
Over 90% of deaths in Hong Kong occur in hospitals. [3]
Hong Kong ranked 22nd in the world (in quality of death index) [3]
~50,000 deaths/year vs ~360 beds in 16 public hospitals (~330 NGO beds). Only 49 specialist palliative care physicians (22 under internal medicine). Low spending on healthcare (7% of GDP). Palliative care not compulsory in undergraduate medical/nursing curriculum. [3]
This gap means that every doctor, not just palliative care specialists, must be competent in EOL care.
What Do Patients Want at the End of Life?
87.3% would prefer to receive care that gives comfort but does not necessarily prolong life. Only 12.4% would choose to prolong life as much as possible even with pain/discomfort. 31.2% would choose to die at home. [3]
There is a massive mismatch between what patients want (comfort) and what hospitals deliver by default (aggressive interventions).
- Be free of pain, anxiety, be kept clean
- Feeling prepared for one's death – affairs in order
- Achieve sense of completion about one's life
- Maintain one's dignity
- Family/friends present (not die alone)
- Have autonomy over treatment decisions
- Have a trusting physician and nurse with whom one feels comfortable and can discuss fears
- Be mentally aware
- Be at peace with God
- Not be a burden to family/society
- Be able to help others
- Have funeral arrangements planned
- Feel one's life is complete
Exam Insight
If asked "what do patients value at EOL that doctors often overlook?", the answer includes spiritual peace, not being a burden, funeral planning, and life completion. Doctors focus on medical symptoms; patients think about meaning, legacy, and relationships.
The 5 Key Steps of Quality EOL Care
This is the core framework of the lecture and the most examinable structure.
STEP 1: Determine Prognosis
People who are "approaching the end of life" = likely to die within the next 12 months, including those with:
- Advanced, progressive, incurable conditions (e.g. metastatic cancer, advanced dementia, advanced HF, ESRD)
- General frailty and co-existing conditions with expected death within 12 months
- Existing conditions at risk of dying from a sudden acute crisis
- Life-threatening acute conditions from sudden catastrophic events (e.g. massive stroke)
"Would you be surprised if the patient were to die within the next year?" If NO → trigger to assess for palliative care needs.
This is a validated screening tool. It's deliberately subjective — it forces the clinician to integrate all the clinical information they know about a patient and make an honest gestalt judgement. When clinicians answer "No, I would not be surprised," these patients have significantly higher mortality.
Three classic trajectories of functional decline before death:
| Trajectory | Disease Examples | Pattern | Palliative Care Timing |
|---|---|---|---|
| Cancer | Metastatic cancer | High function → rapid decline in last weeks-months | Clear terminal phase; palliative care often started early |
| Organ Failure | CHF, COPD, ESRD | Gradual decline with acute exacerbations; each exacerbation may be fatal, but recovery possible | Unpredictable; hard to know which exacerbation is the last |
| Frailty/Dementia | Advanced dementia, general frailty | Prolonged, gradual decline; very low baseline function | Often not recognised as "dying"; EOL care delayed |
Why organ failure patients get more aggressive care: Each exacerbation looks like a potentially reversible crisis. Clinicians hesitate to "give up." But the overall trajectory is still downward — each recovery is to a lower baseline. Recognising this pattern is key to initiating EOL conversations between exacerbations.
Why dementia is a terminal illness: The lecture explicitly states this.
Dementia is a terminal illness. [3]
This is a critical concept. Dementia patients die from dementia — through progressive loss of swallowing, immune function, and eventually brainstem-mediated vital functions. They don't just die with dementia.
Tool 3: Prognostic Indices and Indicators
Stage Description 1 No difficulties (normal) 2 Subjective forgetfulness (normal) 3 Decreased job functioning and organisational capacity (early) 4 Difficulty with complex tasks, instrumental ADLs (mild) 5 Requires supervision with ADLs (moderate) 6 Impaired ADLs, with incontinence (moderately severe) 7A Ability to speak limited to six words (severe) 7B Ability to speak limited to single word 7C Loss of ambulation 7D Inability to sit 7E Inability to smile 7F Inability to hold head up
Advanced dementia (FAST ≥ 7): Median survival 1.3 years (Mitchell et al., NEJM 2009) [3]
Mrs. Wong would be FAST 7A or beyond (she has dementia and is wheelchair-bound, refusing food). This places her squarely in "advanced dementia" with a median survival of ~1.3 years, and the actual survival is likely shorter given her recurrent admissions and weight loss.
- Advanced HF — NYHA Stage 3 or 4 with symptoms despite optimal HF therapy
- Repeated admissions with HF — 3 admissions in 6 months or a single admission aged > 75 (50% 1-year mortality)
- Severe untreatable coronary artery or peripheral vascular disease
- Difficult ongoing symptoms despite optimal tolerated therapy
- FEV1 < 30% predicted, persistent symptoms despite optimal therapy
- Recurrent hospital admissions (≥3 in last year due to COPD)
- Hypoxia/fulfilling LTOT criteria (PaO2 < 7.3 kPa)
- Too unwell for surgery or pulmonary rehabilitation
- MRC grade 4/5 — shortness of breath after 100 metres on level surface
- Required ICU or NIV during admission, or ventilation contraindicated
- Increasing dependence in most ADLs
- Multiple co-morbidities
- General physical decline and increasing need for support
- Decreasing response to treatments (irreversibility)
- Choice of no further active treatment
- Progressive weight loss ( > 10%) in past 6 months (albumin < 25 g/L)
- Repeated unplanned/crisis admissions
High Yield for Exams
The GSF General Indicators apply to ALL diagnoses. If you see a patient with ≥3 of these features (declining ADLs, weight loss > 10%, albumin < 25, repeated admissions), they meet criteria for "approaching end of life" regardless of specific diagnosis. This is often tested in MCQ format.
STEP 2: Understand Treatment Options
Main purpose of treatments: (1) Prolong life, (2) Promote comfort/maintain quality of life, (3) Preserve function. [3]
Treatment tradeoffs: Prolonging life → poorer quality of life? (e.g. dialysis, mechanical ventilation). Consider likelihood of success and alternatives. [3]
The lecture shows a balance/seesaw diagram between "Prolong life" and "Quality of life." The key principle is that as prognosis worsens, the balance should shift toward quality of life.
This is a centrepiece of the lecture and explicitly listed as required reading in the AOS [2].
The correct answer to the MCQ-style question on the slide: [3]
B. Tube feedings have not been shown to prevent recurrent aspiration pneumonia or prolong life.
This is the evidence-based answer. Option A is partially true (it IS uncomfortable) but incorrectly states it may prolong life. Option C incorrectly states it may prevent aspiration pneumonia.
Setting: Advanced dementia (FAST ≥ 7A) patients in 2 geriatric convalescent hospitals, 2016–2019. 764 subjects: 464 NGT feeding (61%) vs 300 careful hand feeding (CHF) (39%).
Results:
- No difference in 1-year mortality (64% NGT vs 63% CHF; p = 0.55)
- No difference in median survival (125 days NGT vs 145 days CHF; p = 0.55)
- Higher pneumonia-free survival for CHF (mean 196 days NGT vs 241 days CHF; p = 0.001)
- NGT feeding associated with 41% higher risk of pneumonia (adjusted HR 1.41, 95% CI 1.04–1.91)
This is remarkable: NGT feeding is not only no better than careful hand feeding for survival — it actually increases the risk of aspiration pneumonia. The mechanism: tube feeds delivered at volume/rate into a stomach with poor motility → gastric distension → reflux → aspiration. The tube also disrupts the lower oesophageal sphincter.
Feeding tubes in advanced dementia:
- Do NOT decrease mortality
- Do NOT reduce rates of aspiration pneumonia
- Do NOT improve functional status
- Do NOT improve pressure ulcer healing
- Do NOT improve nutritional status
- Do NOT decrease rates of hospitalisation
- Incorrect insertion into airway
- GI bleeding
- Diarrhoea/vomiting
- Dislodgement, blockage → repeated reinsertions
- Restraint use to prevent self-removal
- Restrict mobility → functional decline
This is a Common Exam Trap
Students (and junior doctors) often state that tube feeding "prevents aspiration" or "provides nutrition to prevent malnutrition." In advanced dementia, BOTH of these statements are false. The evidence clearly shows no benefit and actual harm. If you write these in an exam, you will lose marks. The correct framing: "Patient is dying from dementia, not from lack of nutrition."
Before concluding someone needs EOL care, always search for reversible causes:
- Chewing difficulties — poor dentition, dry mouth
- Decreased sense of taste, smell
- Oral ulcers, thrush
- Side effects from medications
- Constipation, nausea
- Depression, anxiety
- Pain
This is important because not every patient with poor oral intake is dying. Treat what's treatable first.
STEP 3: Communicate with Patients and Families
1. Explain disease prognosis:
- "I expect patient is near the end of life because she is at an advanced stage of dementia"
- "Patient is dying from dementia and not from lack of nutrition"
2. Explain treatment options and expected outcomes, benefits and risks:
- "Feeding tube unlikely to reduce aspiration risk or improve life expectancy, but has many risks and negatively impacts quality of life"
3. Present alternatives
4. Address concerns and worries
The main goal is to promote comfort and quality of life. Food consistency may be modified. Nutritious supplements may be added. Trained caregivers feed using strategies to reduce choking/aspiration risk.
Downsides of CHF (be honest about these in exams) [3]
- Can be time-intensive
- Fears of causing choking among carers
- May not be able to give essential medications
- Patient will lose weight if intake is poor
The key difference: these downsides are expected consequences of the dying process, not harms caused by the intervention. Losing weight when dying is natural. Causing GI bleeding from a tube is iatrogenic.
NOT "feeding tube or no feeding tube (do nothing)" → but "choice of feeding tube vs careful hand feeding to maximise patient comfort" NOT "we will withhold CPR" → but "we allow patient to die naturally and with dignity"
This is crucial communication skill. Never frame comfort care as "doing nothing." You are doing the most important thing — ensuring comfort and dignity.
In very advanced dementia, some will no longer swallow food or liquid. This may indicate the patient is nearing the end of life. Stopping eating and drinking is a natural part of the dying process. At this stage, patients often do not feel hungry.
Things we can do:
- Keep mouth and lips moist and clean
- Relieve pain and other symptoms with medications
- If indicated, fluids can be given IV to keep the person hydrated
"Communication is one of our most important procedures." [3]
Assess patient's nonmedical goals and values. [3]
Ask surrogate to be the patient's voice (substituted judgement):
- "What is most important to your loved one at this time?"
- "What would your loved one hope for?"
- "What would she be most worried about?"
Substituted judgement means the surrogate speaks for the patient based on the patient's known values, not the surrogate's own wishes. This is a key legal and ethical concept.
What matters most to patients is not the treatments themselves but the impact of the treatment on their life:
- Best outcome
- Worst outcome
- Most likely outcome [3]
Frame discussions around outcomes ("If we insert the tube, the best case is... the worst case is... the most likely outcome is..."), not around the procedure itself.
Mrs. Wong's daughter says: "My mother was a great cook and loves to eat. She wouldn't want the feeding tube if she can no longer enjoy the taste of food. It would not be a meaningful life to her."
Plan: Start careful hand feeding and training of caregivers. Communicate plan with team members and care providers at OAH. [3]
The care plan must be:
- Aligned with the patient's expressed/inferred values
- Communicated to all team members (this prevents the next on-call doctor from inserting an NGT)
- Documented clearly (in HK context: ACP documentation, DNACPR form, clinical notes)
ACP is an overarching process of proactive communication regarding EOL care. Through this process, a patient with advanced progressive disease, their healthcare providers, family members and caregivers can consider ahead of time what kind of care is appropriate when the patient can no longer make a decision. [3]
ACP is NOT a single form or document — it's a process of ongoing conversation. It should ideally happen before a crisis, while the patient still has capacity.
Recommendations to Promote Quality EOL Care [3]
- Initiate advance care planning before crisis event
- Proactive symptom assessment and management
- Refer to end-of-life care programme at OAH or palliative care
- Align care plan with goals
- Honour preferred place of care (e.g. home, nursing home, hospital)
Care of the Imminently Dying: Comfort Care Measures
Common symptoms in dying patients:
- Dyspnoea
- Xerostomia (dry mouth)
- Nausea and vomiting
- Constipation
- Anorexia and cachexia
- Fever
- Terminal delirium
- Anxiety and insomnia
- Excessive secretions
Anticipatory prescribing may be helpful. [3]
"Anticipatory prescribing" means writing PRN orders in advance for common symptoms of dying (e.g. morphine SC PRN for pain/dyspnoea, midazolam for agitation, hyoscine for secretions, haloperidol for nausea/delirium) so the nursing staff can administer them without waiting for a doctor.
- Consider discontinuing ventilator, dialysis, antibiotics
- Minimise/stop blood draws
- Recommend DNACPR order
- Discuss no further escalation of care (no pressors, blood products, antibiotics)
- Determine benefit/risks of IVF
- Deactivate ICD
- Reduce frequency of vital signs, turn off monitors
Why turn off monitors? Because alarms cause distress to patients and families without providing actionable clinical information when death is expected. The focus shifts from numbers to the patient.
Why deactivate ICD? An implantable cardioverter-defibrillator will deliver painful shocks during the dying process as arrhythmias develop. This causes unnecessary suffering.
- Move patient to more private space and liberalise visiting hours for family members
- Ensure respectful and dignified care (skin, oral, bladder/bowel care to maximise comfort)
- Communicate treatment plan with healthcare team and family (reassure non-abandonment)
"Reassure non-abandonment" is crucial. Families fear that choosing comfort care means doctors will stop caring. Explicitly say: "We are not abandoning your mother. We are changing the focus of care to ensure she is comfortable."
Physical signs/symptoms:
- Irregular breathing patterns (may pause before resuming — Cheyne-Stokes)
- Noisy breathing ("death rattle")
- Coolness of extremities and pale, bluish/mottling of skin
- Sleeping most of the time / unresponsiveness
- Urine or bowel incontinence
- Terminal delirium (disorientation, yelling, restlessness)
Practical preparations: Funeral arrangements. [3]
- Keep loved one warm with blanket
- Help provide daily care — mouth care, moisten lips, sips of water if able, comb hair, skin care
- Spend time at bedside, hold loved one's hand
- Tell stories of loved one's life
- Assume person can hear — hearing is one of the last senses to go. Talking to loved one can provide comfort.
Important time for families to seek reconciliation and say goodbye to loved one. [3]
- On-call chaplain available 24/7
- Consult palliative care for psychosocial support
- Refer MSW for bereavement support
Legal and Ethical Framework (Integration from Past Papers and Supporting Material)
In HK, under the Mental Health Ordinance Part IVC:
- The doctor, NOT the next-of-kin, has legal authority to make treatment decisions for MIPs who lack capacity
- Decision must be in the patient's best interests: save life, prevent damage/deterioration, bring improvement
- Previously expressed wishes should be considered (e.g. ACP)
- Adopt the least restrictive alternative
The 2019 SAQ Q12 asks: Mrs. Chan, 87, early dementia, told a clinical team she wanted DNACPR but no formal DNR in notes. She arrives in cardiac arrest. Family insists on CPR.
Arguments FOR resuscitation:
- Autonomy: no valid documented DNACPR → cannot confirm wishes
- Beneficence: CPR may restore life
- Non-maleficence: inaction may cause preventable death
Arguments AGAINST resuscitation:
- Autonomy: patient previously expressed DNACPR wish (even if undocumented)
- Non-maleficence: CPR in frail elderly has very low success rate and may cause suffering (rib fractures, hypoxic brain injury)
- Patient's previously expressed wishes should carry weight even if not formally documented
What to do: In practice, without a valid documented DNACPR, you should commence CPR (legal default) while rapidly assessing the situation and the validity of the patient's prior expressed wishes.
The 2021 minicase asks for the definition:
Life-sustaining treatment = any treatment that serves to prolong life without reversing the underlying medical condition. It includes but is not limited to: CPR, artificial ventilation, artificial nutrition and hydration (tube feeding), blood products, antibiotics for life-threatening infections, dialysis, vasopressors/inotropes.
- Patient has capacity and refuses treatment (autonomy)
- Valid advance directive refusing treatment
- Treatment is futile (no reasonable prospect of benefit)
- Burdens of treatment outweigh benefits
- Treatment is not in the patient's best interests
- Guardian/court authorises withdrawal
1. Providing care to the dying is the responsibility of ALL medical providers. 2. The skills of prognostication are important to recognise patients who can benefit from a palliative care approach. 3. Developing an individualised care plan should take into account the prognosis, treatment options, goals of care, and requires good communication. 4. Attend to the physical, psychological, and spiritual needs of patients and family members in caring for the dying.
"To cure sometimes, to relieve often, to comfort always." — Edward Livingston Trudeau [3]
Likely Exam Questions
-
"An 88-year-old man with FAST 7B dementia is admitted with aspiration pneumonia for the 3rd time in 6 months. His family asks about inserting a PEG tube. Discuss."
- State prognosis (advanced dementia, median survival 1.3 years, likely shorter given trajectory)
- Cite evidence: feeding tubes do NOT decrease mortality, do NOT reduce aspiration pneumonia, do NOT improve functional status or nutritional status
- List harms: GI bleeding, restraint, dislodgement, restricted mobility
- Recommend careful hand feeding as alternative
- Communicate using the 5-step framework
-
"List 4 general prognostic indicators suggesting a patient is approaching end of life."
- Increasing dependence in ADLs, weight loss > 10% in 6 months (albumin < 25), repeated unplanned admissions, decreasing response to treatments
-
"List 5 comfort care measures for an imminently dying patient."
- Anticipatory prescribing for symptoms, DNACPR, discontinue non-comfort treatments, move to private space/liberalise visiting, mouth/skin care, turn off monitors
-
"What is advance care planning? When should it be initiated?"
- ACP = overarching process of proactive communication regarding EOL care; should be initiated BEFORE a crisis event, while patient has capacity
-
"Which of the following is TRUE about NGT feeding in advanced dementia?"
- Correct: NGT feeding does NOT reduce aspiration pneumonia rates and may INCREASE pneumonia risk
- Distractors: "reduces mortality," "improves nutritional status," "prevents pressure ulcers"
-
"An 85-year-old with CFS 8 (very severe frailty) presents with confusion and poor intake. What is the most appropriate management?" [6]
- Correct: B — Focus on comfort measures and palliative care, respecting dignity and preferences
- Why others are wrong: Aggressive diagnostics/intensive rehab won't reverse very severe frailty
High Yield Summary
5 Key Steps for Quality EOL Care: (1) Determine prognosis (Surprise Question, disease trajectories, FAST, GSF indicators), (2) Understand treatment options (benefits vs burdens), (3) Communicate with patients/families (explain prognosis, present alternatives with positive framing), (4) Clarify goals of care (substituted judgement, nonmedical values), (5) Recommend care plan matching goals.
Feeding tubes in advanced dementia: Do NOT decrease mortality, do NOT reduce aspiration pneumonia, do NOT improve function/nutrition/pressure ulcers. NGT feeding increases pneumonia risk by 41% (HK study). Alternative = careful hand feeding. "Patient is dying FROM dementia, not FROM lack of nutrition."
Comfort care for imminently dying: Anticipatory prescribing (morphine, midazolam, hyoscine), DNACPR, stop non-comfort treatments, deactivate ICD, turn off monitors, private space, mouth care, family involvement. Hearing is the last sense to go.
ACP: Proactive communication process, initiated before crisis, while patient has capacity. Document in notes. In HK, doctor makes final treatment decision for MIPs (not next-of-kin), guided by best interests and previously expressed wishes.
87.3% of HK adults prefer comfort over life prolongation at EOL. Over 90% of deaths in HK occur in hospitals. 31.2% would prefer to die at home.
Active Recall - End-of-Life Care for Hospitalised Older Adults
[1] AOS - Geriatrics.pdf (Required readings: Chapter 19 End-of-life Care) [2] Geriatrics AOS.pdf (Required readings: Chapter 19, Backgrounder on Feeding Tubes in Advanced Dementia) [3] Lecture slides: GC 045. End-of-life care for hospitalised older adults.pdf (all pages) [4] Past papers: 2019 Fourth Summative SAQ.pdf (Question 12 — DNACPR scenario) [5] Past papers: 2021 Fourth Summative Minicase.pdf (Section 3 — life-sustaining treatment definition, withholding/withdrawing) [6] AOS - Geriatrics.pdf (CFS 8 MCQ scenario — comfort care vs aggressive management) [7] Past papers: 2020 Fourth Summative Minicases.pdf (Section 4 — palliative care in metastatic cancer) [8] Senior notes: Ryan Ho Psychiatry.pdf (p.9 — decision-making for mentally incapacitated persons under MHO)
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