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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.

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].

Learning Objectives (from the lecture) [3]

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.

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) tube dislodgement led to restraint and repeated instrumentation, adding substantial burden. Restraint, if ever considered for immediate safety, requires a clear indication, proportionality, frequent review and the least-restrictive alternative.

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.

The slides use older datasets to show how acute-care use differed by disease trajectory. The disease table is from a 2010-era source, the place-of-death slide cites 2016 reporting, and the “quality of death” rank is from 2015. Treat these as historical teaching snapshots, not current service-performance data.

CancerCOPDCHF
Hospitalisation days (last 6 months)284640
Deaths in ICU0.3%2.1%2.3%
Invasive ventilation0%10%14%
Non-invasive ventilation1%46%13%
CPR4%15%21%

Interpretation: In this dataset, people with COPD or CHF received more intensive interventions near death than people with cancer. A plausible contributor is the less predictable, crisis-and-recovery trajectory of organ failure; the table itself does not establish why the difference occurred.

Over 90% of deaths in Hong Kong occurred in hospitals in the historical dataset shown. [3]

Hong Kong ranked 22nd in the world (in quality of death index) [3]

Place of Death: International Comparison [3]

Country/RegionHospitalHomeOthers (incl. elderly home)
Hong Kong90%1%9%
Singapore61%27%12%
Taiwan40%40%20%
UK48%23%29%

This slide illustrates a large historical gap between hospital and non-hospital deaths. It should not be used as a current estimate without checking contemporary territory-wide data.

~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]

These figures describe the lecture's older service-capacity snapshot rather than the current workforce or bed stock. The durable teaching point is that every doctor, not only palliative-care specialists, needs core EOL-care competence.

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]

This population survey shows that comfort was the majority preference in that sample. It does not predict any individual patient's goals: ask the person, revisit preferences over time, and avoid inferring wishes from age, diagnosis, family opinion, or survey averages.

  • 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 an identification prompt, not a countdown clock or stand-alone prognostic test. A “No” answer should trigger a holistic needs assessment, review of reversibility, communication and proactive planning; it does not prove that death will occur within a year. The 2022 GSF guidance explicitly frames it as an intuitive whole-picture prompt for improving quality of life now and preparing for possible decline [17].

Three classic trajectories of functional decline before death:

TrajectoryDisease ExamplesPatternPalliative Care Timing
CancerMetastatic cancerHigh function → rapid decline in last weeks-monthsClear terminal phase; palliative care often started early
Organ FailureCHF, COPD, ESRDGradual decline with acute exacerbations; each exacerbation may be fatal, but recovery possibleUnpredictable; hard to know which exacerbation is the last
Frailty/DementiaAdvanced dementia, general frailtyProlonged, gradual decline with intermittent setbacks; timing is highly variableOften not recognised as life-limiting; supportive care may be delayed

Why the organ-failure curve matters: Each exacerbation may be reversible, but it may also be the final crisis; recovery often returns the person to a lower functional baseline. Use the period between exacerbations for anticipatory planning while continuing disease-directed treatment when it remains beneficial. Palliative care and active treatment are not mutually exclusive.

Why dementia is a terminal illness: The lecture explicitly states this.

Dementia is a terminal illness. [3]

This is a critical concept. Advanced dementia can itself be life-limiting: progressive functional dependence, dysphagia, eating problems, infection and frailty form part of its terminal trajectory. Avoid treating every episode of poor intake as an isolated calorie deficit while still looking for reversible causes.

Tool 3: Prognostic Indices and Indicators

StageDescription
1No difficulties (normal)
2Subjective forgetfulness (normal)
3Decreased job functioning and organisational capacity (early)
4Difficulty with complex tasks, instrumental ADLs (mild)
5Requires supervision with ADLs (moderate)
6Impaired ADLs, with incontinence (moderately severe)
7AAbility to speak limited to six words (severe)
7BAbility to speak limited to single word
7CLoss of ambulation
7DInability to sit
7EInability to smile
7FInability to hold head up

Advanced dementia (FAST ≥ 7): Median survival 1.3 years (Mitchell et al., NEJM 2009) [3]

The slide's cohort-level median survival must not be converted into an individual deadline. Mrs Wong's FAST stage also cannot be assigned from “wheelchair-bound” and food refusal alone: FAST staging requires the ordered dementia-related functional losses, including the specified language and mobility milestones. Recurrent admissions, weight loss and eating problems still justify a broader prognostic and palliative-needs assessment.

Clinical course of advanced dementia (Mitchell et al., NEJM 2009): In a cohort of nursing-home residents with advanced dementia (median age 86, median dementia duration 6 years, 85% female), cumulative incidence over 18 months was approximately [3]:

  • Eating problems: ~86% (the most common complication)
  • Febrile episodes: ~53%
  • Pneumonia: ~41%
  • Death: ~55%

This underscores that eating problems are the hallmark complication of advanced dementia and are part of the disease trajectory, not a separate nutritional problem to be "fixed" with tube feeding.

  • Advanced HF — NYHA functional class III or IV 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
  • Severe breathlessness: MRC grade 4 (stops after about 100 metres on the level) or grade 5 (too breathless to leave the house/dress independently)
  • Required ICU or NIV during admission, or ventilation contraindicated

These disease-specific features are prompts for supportive/palliative assessment, not precise individual survival predictions and not reasons to stop indicated heart-failure or COPD treatment.

  • 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 across diagnoses, but the slide gives prompts, not a diagnostic score or eligibility threshold. A cluster such as declining ADLs, weight loss and repeated crisis admissions should trigger holistic assessment and proactive care planning; it does not by itself prove a 12-month prognosis.

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's balance/seesaw image asks what each treatment is likely to achieve and what living with its burdens would be like. Do not assume that prognosis alone dictates the answer: elicit the patient's priorities, explain best/worst/most-likely outcomes, and recommend the option whose expected benefits and burdens best fit those priorities.

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)

Subgroup analyses (Yuen et al., JAMDA 2022) [3]:

  • Survival: No significant difference between NGT and CHF regardless of feeding-problem subtype — behavioural feeding problem (p = 0.53), dysphagia (p = 0.19), or coexisting behavioural + dysphagia (p = 0.99).
  • Pneumonia risk: The increased pneumonia risk with NGT was most pronounced in patients with coexisting behavioural feeding problems and dysphagia (p = 0.012), while no significant difference was seen in the dysphagia-only subgroup (p = 0.89).

This retrospective cohort found no survival advantage and an association between NGT feeding and more pneumonia. Because feeding mode was not randomised, the adjusted hazard ratio does not by itself prove that the tube caused every excess event; it does directly refute the promise that NGT reliably prevents aspiration in this population.

Routine feeding-tube use in advanced dementia has not been shown to:

  • Decrease mortality
  • Reduce aspiration-pneumonia rates
  • Improve functional status
  • Improve pressure-ulcer healing
  • Reliably improve nutritional status
  • Decrease hospitalisation rates

NICE therefore advises not to use enteral feeding routinely in severe dementia, except when a potentially reversible comorbidity is causing the eating/swallowing problem and recovery of oral intake is expected [12]. This is not a blanket ban on all artificial nutrition in every patient: identify the indication, likely duration, reversible cause, goals, and burdens for the individual.

  • 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

Do not promise that a feeding tube will prevent aspiration or prolong life in advanced dementia. Explain the uncertainty and burdens, correct reversible causes, and offer active alternatives such as careful hand feeding. The phrase “dying from dementia, not simply from lack of calories” can help explain the trajectory, but should not replace an individual assessment.

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

These are real trade-offs: careful hand feeding requires time, caregiver training and ongoing review; choking/aspiration cannot be eliminated, and intake may remain insufficient. Its goal is comfort, human interaction and oral enjoyment—not a guarantee of adequate calories or risk-free swallowing.

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,” but do not use positive framing to steer or conceal uncertainty. Name both options neutrally, explain what CPR or tube feeding can and cannot achieve, check understanding, invite questions, and make a reasoned recommendation linked to the patient's goals.

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, clinically assisted hydration can be considered as an individualised therapeutic trial

For a person in the last days of life, assisted hydration has uncertain effects on survival and the dying process. Consider a time-limited trial when thirst, delirium or another distressing feature may relate to dehydration and oral intake is inadequate; monitor for benefit and harms such as oedema, pulmonary congestion or infusion discomfort, and reduce or stop if harm outweighs benefit [13]. Mouth and lip care remains essential whether or not fluids are used.

"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 family helps reconstruct the patient's known values and prior wishes rather than substituting their own preferences. In Hong Kong, this ethical role does not make every next-of-kin a general legal proxy. The treating clinicians remain responsible for best-interests decisions for a mentally incapable adult, subject to any valid and applicable advance medical directive; the statutory DNACPR process has specific clinician and responsible-person requirements (see the current-law box below) [14][16].

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:

  1. Aligned with the patient's expressed/inferred values
  2. Communicated to all team members (this prevents the next on-call doctor from inserting an NGT)
  3. 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.

Current Hong Kong law (in force from 31 July 2026)

The Advance Decision on Life-sustaining Treatment Ordinance (Cap. 651) now provides the statutory framework for advance medical directives (AMDs) and DNACPR orders [14][15]. A valid and applicable AMD made by a mentally capable adult can refuse specified life-sustaining treatment for a future period of incapacity. For a mentally incapable adult without an AMD refusal of CPR, a non-AMD-based DNACPR order is a clinician-led best-interests decision using the prescribed process, including two registered medical practitioners and the agreement/co-signature of the responsible person. A DNACPR order concerns CPR only; all other treatments and basic/palliative care require separate, individual consideration [14][16].

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 preparing access to medicines for symptoms that are reasonably likely to arise, with an individual indication, dose and route. It is not a blanket “dying protocol”: assess the actual symptom and reversible causes before administration, follow local palliative-care guidance (including renal/hepatic adjustment), then monitor benefit and adverse effects at least daily [13].

  • 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

Each item is an individual treatment decision, not an automatic bundle. Antibiotics, dialysis, transfusion or hydration may sometimes relieve symptoms or meet a time-limited goal; continue them when their expected benefit fits the care plan and stop them when burdens outweigh benefit. A DNACPR order means only that CPR will not be attempted at arrest—it does not mean “no treatment,” “ward care only,” or abandonment [14][16].

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
  • Speak gently as though the person may still hear; a familiar voice and touch may provide comfort even without a visible response.

Important time for families to seek reconciliation and say goodbye to loved one. [3]

  • Offer chaplaincy or faith-community support according to the patient's wishes and local availability
  • Consult palliative care for psychosocial support
  • Refer MSW for bereavement support

Legal and Ethical Framework (Current HK Position + Historical Exam Material)

In Hong Kong:

  • Assess capacity for the specific treatment decision at the relevant time; dementia does not automatically remove capacity.
  • A valid and applicable AMD under Cap. 651 prevails for the life-sustaining treatment it refuses [14][16].
  • Otherwise, treating clinicians make treatment decisions for a mentally incapable adult on a best-interests basis, informed by the person's prior values/wishes and discussion with family; ordinary next-of-kin status is not a general power of attorney.
  • A non-AMD-based DNACPR order for a mentally incapable adult follows the statutory process described above. Family contributes to consensus and the responsible person co-signs agreement with the clinical best-interests judgment; the order remains clinician-made [14][16].

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

Current practice point: In an emergency there is presumed consent for clinically indicated CPR. If a valid/applicable AMD refusal or DNACPR order is known, it should be followed. If validity or applicability is genuinely uncertain, start CPR as clinically indicated while proof is clarified; however, clinicians are not obliged to provide futile or non-beneficial CPR. Document the reasoning and communication [16].

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
  • A lawful best-interests process supports the decision for a patient lacking capacity, while any dispute or uncertainty requiring legal determination is escalated appropriately

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]

High Yield Summary

  1. 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, positive framing
    • (4) Clarify goals of care: substituted judgement, nonmedical values
    • (5) Recommend care plan matching goals

  2. Feeding tubes in advanced dementia:

    • Routine use has not been shown to decrease mortality or reduce aspiration pneumonia
    • Routine use has not been shown to improve function, nutrition, or pressure-ulcer healing
    • The HK 2022 retrospective cohort found NGT was associated with 41% higher pneumonia risk; association is not proof of causation
    • NICE: do not use enteral feeding routinely in severe dementia unless a potentially reversible comorbidity provides a time-limited indication
    • Exam phrase: "Patient is dying FROM dementia, not FROM lack of nutrition."

  3. Comfort care for the imminently dying:

    • Anticipatory prescribing: individual indication, dose and route; reassess before administration and monitor response
    • DNACPR concerns CPR only; review every other treatment separately; consider ICD deactivation and non-beneficial monitoring
    • Private space, liberalise visiting, mouth/skin care, family involvement
    • Speak gently as though the person may still hear; familiar voices and touch may comfort

  4. ACP (Advance Care Planning)

    • Proactive communication process—initiate before crisis while the patient has capacity and document clearly
    • Under current HK Cap. 651, valid/applicable AMDs and statutory DNACPR orders have defined requirements; ordinary next-of-kin status is not a general proxy

  5. HK lecture statistics are historical snapshots

    • The survey found 87.3% preferred comfort and 31.2% home death; the hospital-death and service-capacity figures should not be presented as current without updated data

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 (Case 3 Q13–15 — 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 (Case 3 Section 4 Q11–13 — palliative care in metastatic cancer) [8] Senior notes: Ryan Ho Psychiatry.pdf (p.9 — decision-making for mentally incapacitated persons under MHO) [12] NICE NG97, Dementia: assessment, management and support — recommendation 1.10.8 on enteral feeding in severe dementia: https://www.nice.org.uk/guidance/ng97/chapter/Recommendations [13] NICE NG31, Care of dying adults in the last days of life — hydration and anticipatory-prescribing recommendations: https://www.nice.org.uk/guidance/ng31/chapter/recommendations [14] Hong Kong Health Bureau, Advance Decision on Life-sustaining Treatment Ordinance — statutory AMD/DNACPR framework and forms: https://www.healthbureau.gov.hk/en/press_and_publications/otherinfo/241100_adlto/index.html [15] HKSAR Government, Advance Decision on Life-sustaining Treatment Ordinance to come into effect on July 31 (22 May 2026): https://www.info.gov.hk/gia/general/202605/22/P2026052200259.htm [16] Hospital Authority Clinical Ethics Committee, HA Guidelines on Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) (23 October 2025): https://www.ha.org.hk/haho/ho/psrm/DNACPREng.pdf [17] Gold Standards Framework, Proactive Identification Guidance, 7th ed. (2022): https://www.goldstandardsframework.org.uk/wp-content/uploads/2025/07/Proactive-Identification-Guidance.pdf

GC044 Electrolyte And Acid-base Disorders

Electrolyte and acid-base disorders are clinical conditions involving abnormal concentrations of key ions (sodium, potassium, calcium, magnesium, phosphate) or disturbances in blood pH homeostasis (acidosis or alkalosis), arising from metabolic or respiratory causes and affecting cellular and organ function.

GC046 Facial Rash And Painful Fingers: SLE

Systemic lupus erythematosus is a chronic multisystem autoimmune disease characterized by autoantibody production (notably anti-dsDNA and anti-Smith), commonly presenting with a malar butterfly rash, photosensitivity, arthritis, and potential involvement of the kidneys, heart, and other organs.

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