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NSG2TBN Case Scenario

Mr. Gray is a 67 year old man who is recovering from a mild stroke and is currently admitted for severe exacerbation of his COPD with dyspnoea on minimal exertion. He has moderate dysphagia and dysphasia.  During the last 48 hours, he has had nocturnal pyrexia and has been more listless and less inclined to interact with his family, staff and other patients.  During morning handover, the night staff reported his temperature was 38.7 C and his oxygen saturations decreased to 89% (SpO2) and he has required continuous intranasal oxygen therapy.


At the commencement of a morning shift, the RN approaches him and notes that he is diaphoretic, looks flushed, glassy eyed, and he is breathing through pursed lips. He remains febrile (38.5 C), is slightly tachycardic P=105, normotensive and has a respiratory rate of 26 breaths per minute. His breakfast is untouched.

The RN decides to assist him with a sponge in bed and administer 1 g of paracetamol to make him more comfortable. When Mr Gray is offered the paracetamol he shakes his head and turns away. The RN encourages him to  take them, but he refuses and becomes agitated and very dyspnoeic. He has a severe cough with small haemoptysis. The RN auscultates his chest and notes decreased breath sounds and wheezing throughout.  The RN sees to his comfort and then contacts the resident medical officer (RMO).

The RMO examines Mr. Gray and orders a chest X-ray, arterial blood gases, maintenance Intravenous Therapy (IVT) at 24/24 and oral antibiotics. Mr. Gray’s provisional diagnosis is pneumonia. Mr. Gray refuses the IVT and oral antibiotics. Throughout the shift, he continues to decline food and only takes small sips of water. He also refuses his prescribed medications except for the oxygen therapy. The medical team question whether the pneumonia is due to aspiration as his gag reflex may not be protective since his recent stroke.   Enteral feeding is considered by the medical team and this will also enable antibiotic therapy.  When the RN and the doctor discuss it with Mr. Gray he indicates that he doesn’t want the naso-gastric tube and again begins to become agitated.  Mrs  Gray is consulted and states she is happy for health care staff to do “anything that needs to be done.” The RMO states that antibiotics and the feeding tube are not really extraordinary treatment and queries whether or not Mr. Gray is competent to decide because of his hypoxia and documented history.  Consequently, the RMO requests the RN to insert the naso-gastric tube.  With Mrs Gray’s assistance the RN inserts the naso-gastric tube. With consideration of the case scenario provided, choose two of the legal/ethical concepts below and discuss them in relation to Mr. Gray.  Within your discussion, compare best evidence-based legal / ethical practice with the care that Mr. Gray received.   Please include a brief introduction and conclusion with your assessment.

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