QuestionSBA
QuestionChoice
As the patient lacks capacity, decisions should be made in their best interests, involving the MDT and next of kin. It is important to remember that fluids and artifical nutrition are medical treatments and should be prescribed only when clinically indicated and when they are likely to help. Nausea and loss of appetite are common symptoms in the last days of life, which may warrant symptomatic management.
10017246
a
Discuss in the MDT as to whether fluids and nasogastric tube insertion are in her best interests
QuestionChoice
If the lack of eating is due to a possible swallowing difficulty, this will undoubtedly be useful, but there is no suggestion of that at present.
10017250
e
Refer to speech and language therapy for assessment
QuestionChoice
This is inappropriate. A more detailed discussion needs to be had to ascertain if these interventions are likely to be helpful and in the patient's best interests, as well as what the goals of treatment are.
10017248
c
Advise IV fluids and NG tube will not be helpful at this stage
QuestionChoice
This may be helpful but it does not address the daughter's concerns about artificial nutrition and hydration.
10017249
d
Encourage oral food and water
QuestionChoice
At this stage, we do not have enough information as to whether these treatments are indicated or were previously by the patient, see above answer for MDT discussion for further information.
10017247
b
Administer IV fluids and insert NG tube
Concept
Chapter
# Summary


WHO Performance status classification categorises patients into different groups dependent on their physical fitness, measured by their ability to perform activities of daily living. It is used to assess their suitability for chemotherapy, and has some prognostic significance. 


Chemotherapy as a treatment is not without its side effects, which can limit quality of life and have negative impacts on other comorbidities. Treatment decisions involve a risk-benefit analysis, and as such a patients' performance status has a significant bearing on what treatment options are most appropriate.


# Classification


The WHO performance status classification categorises patients as:


- 0: able to carry out all normal activity without restriction
- 1: restricted in strenuous activity but ambulatory and able to carry out light work
- 2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
- 3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden
- 4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.


# References

[NICE Appendix C: WHO performance status classification](https://www.nice.org.uk/guidance/ta121/chapter/appendix-c-who-performance-status-classification#:~:text=The%20WHO%20performance%20status%20classification,to%20carry%20out%20light%20work)

[JAMA Oncology: Performance status in patients with cancer](https://jamanetwork.com/journals/jamaoncology/fullarticle/2432463)
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623
WHO Performance Status
Topic
25
Oncology and Palliative Care
15993
In patients nearing end-of-life, decisions about artificial nutrition and hydration should prioritize their best interests and overall quality of life, with input from an MDT (multidisciplinary team) to ensure comprehensive care and shared decision-making.
An 88 year old woman has stage 4 breast cancer with metastases in the brain, liver and lungs. It is felt she may be nearing the end of her life, and is currently bedbound with a WHO performance status of 4. She is unable to demonstrate capacity to make treatment decisions. Her daughter requests her mother is given intravenous fluids and is NG tube fed as she has not been eating and drinking for the last few days. There is no formal lasting power of attorney in place.

What is the most appropriate course of action?
a