Education And Debate

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

BMJ 1997; 315 doi: (Published 06 December 1997) Cite this as: BMJ 1997;315:1530

The case history

  1. J McFadzean, registrar in anaesthesiaa,
  2. J P Monson, reader in medicinea,
  3. J D Watson, senior lecturer in intensive care medicinea,
  4. J H Coakley, consultant in intensive care medicine (
  1. a St Bartholomew's Hospital, London EC1A 7BE
  1. Correspondence to: Dr Coakley


    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 …

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