MSGM Clinical Case Discussion February 2026

The Last Chapter: Planning the END, Leaving in PEACE

Prepared by: Dr Sharalaa Devi Engatramana

Supervisor: Dr Loh Siew Ping

Location: Hospital Tengku Ampuan Rahimah, Klang

Case 1

Madam SG is a 74-year-old Indian woman who has been a nursing home resident since 2020. She has a Clinical Frailty Scale (CFS) score of 7, with a background history of advanced Alzheimer’s disease with behavioural and psychological symptoms of dementia (BPSD) Stage 7C, as well as diabetes and hypertension. She has required multiple nursing home transfers due to significant behavioural challenges impacting welfare of other residents. Her daughter, Mrs A, is her primary family contact and oversees her care needs.

Madam SG has had multiple hospital admissions since early 2025. In April 2025, she was admitted for poor glycaemic control related to uncontrolled eating habits and was discharged after five days with medication adjustments. Nursing home staff were advised on timely medication administration and dietary modifications. Despite these measures, her overall condition in the nursing home continued to decline, with worsening cognition, behaviour, and social interaction.

6 months post discharge, Madam SG developed diarrhoea with episodes of hypotension needing admission. She developed Enterococcus bacteremia complicated with hypoactive delirium. She was only treated with antibiotics for 5 days as daughter insisted to be discharged and was not keen for further intervention. Complications that may arise following incomplete treatment, which also may lead to worsening delirium explained, however decision was made.

Madam SG was readmitted within 2 weeks of discharge due to worsening behaviour and poor oral intake. On assessment, she was found to be significantly dehydrated with episodes of hypotension. Blood tests showed severe hypernatremia with acute kidney injury. Imaging revealed chronic cerebral infarcts with generalized brain atrophy, and a chest X-ray showed right lower zone consolidation. Her hospital stay was complicated by prolonged delirium, and following her previous discharge, she developed a grade 2 sacral sore, reflecting her increasing frailty and vulnerability. A nasogastric tube was inserted for feeding due to poor oral intake. She was treated for hospital acquired pneumonia with hypovolemic hypernatremia and Delirium.

Given her severe dementia, frequent admissions, and persistent delirium, a family conference was held to discuss end-of-life care. The family could not reach consensus on limiting interventions and declined removal of the nasogastric tube, insisting on continued feeding and blood tests, struggling to accept that her condition had become terminal.

Case 2

Mr RJ, a 66-year-old man with a premorbid CFS of 4 and a history of type 2 diabetes, hypertension, and ischemic heart disease (managed conservatively in primary care), presented in 2023 with 1 year history of left-hand resting tremor, cogwheel rigidity, bradykinesia, hypomimia, and upward gaze palsy. There was no postural hypotension or instability. Neurological assessment was consistent with Progressive Supranuclear Palsy – Richardson syndrome, and he was started on oral Madopar 62.5 mg TDS.

In December 2023, Mr RJ was admitted with sudden-onset left-sided hemiparesis and treated for a right lacunar infarct. After discharge, his symptoms gradually worsened, and by mid-2024 he developed postural instability and constipation, requiring supervision for mobility but remained independent in basic activities. Antiparkinsonian therapy was optimized with entacapone and benzhexol, recognizing the lack of a definitive treatment for the disease. MRI brain degenerative protocol showed only mild cortical atrophy, with no definitive features of PSP, but treatment continued based on clinical presentation. Occupational therapy and physiotherapy referrals were arranged to support gait and balance.

His primary carers are his daughter and wife, with the daughter balancing work alongside caregiving responsibilities. Due to difficulties attending hospital physiotherapy appointments and limited resources for private physiotherapy, his lower limb and trunk stiffness progressed, leading to significant mobility challenges, causing him to become bed-bound by mid-2025.

Subsequent months showed rapid deterioration of Mr RJ’s condition. In August 2025, Mr RJ was admitted with an NSTEMI complicated by hospital-acquired pneumonia and a grade 2 pressure sore. He had recurrent admissions in October for unstable angina, recurrent strokes, and deconditioning. In November, he sustained a fall while changing diapers, leading to readmission with septic shock secondary to pneumonia and delirium. He developed choking episodes to both fluids and solids, requiring a nasogastric tube. Following these recurrent events, his condition declined, and he became fully dependent due to rigidity in all limbs and loss of sitting balance. With comprehensive nursing care, physiotherapy, and cognitive stimulation, he showed minimal improvement but never regained his baseline function

Following the rapid progression of his disease, a family conference was held to discuss advanced care planning, including his preferences, as well as financial and property matters. Post-discharge planning emphasized the need for continuous care, assistance with bed mobility, pressure sore prevention, and caregiver training. Mr RJ was referred to palliative care, with arrangements made for a domiciliary team visit.

Questions to ponder

1. What are the differences between advance care planning (ACP) and end of life care?

2. What is the main key barrier in initiating the process of discussion regarding the above mentioned?

3. In Case 1, the treating physician found it challenging to help the family come to terms with the patient’s terminal condition. Why do you think so?

4. What is your take in the effect of cultural beliefs and language barriers in decision making for a patient in the terminal stage of life?

5. Filial piety has a strong influence in cultural decision making and a seemingly insurmountable challenge. How can respect for belief systems be balanced with honest communication about the patient’s terminal stage of life?

6. In Case 2, given the anticipated rapid disease progression, advance care planning is pertinent. What would be the optimal timing to initiate discussion on ACP with the family?

7. ACP conversations should involve a core triad. Who are the key stakeholders that should ideally participate in the discussion?

8. Advance care planning will lead to advance directives that is a legal document that specifies treatment option decided. What is the core discussion that involves in the Mental Capacity Act?

9. The social circumstances of Mr. RJ’s family have unfortunately posed barriers to optimal patient care. How can the healthcare system nonetheless ensure adequate support and comfort for the family?