Ethical debate: The dilemma of the incapacitated patient who has previously refused consent for surgery

Introduction

A 72 year old Italian woman who spoke little English was admitted to hospital with a minor haemoptysis. Her medical history was complex. She had asthma, oesophageal varices, and recurrent small pulmonary embolisms, and had undergone partial thyroidectomy for a multinodular goitre. Her medication included salbutamol, ipratropium, becotide, warfarin, and thyroxine. Physical examination showed that the patient weighed 105 kg and had a large neck swelling that extended retrosternally. Her condition was otherwise stable.

A provisional diagnosis of minor pulmonary embolism was made, and the patient was given treatment to relieve symptoms overnight. The following morning she had an acute upper airway obstruction as a result of haemoptysis. She was resuscitated by the cardiac arrest team, intubated and ventilated, and was then transferred to the intensive care unit, where her …