Hypothetical:

So whose choice is it anyway?

Facilitator: Prof Liz Reymond

MBBS (Hons), PhD, FRACGP, FAChPM

Brisbane South Palliative Care Collaborative

RACF inaugural conference

16 November 2017

Trigger 1: Dr Terry Nash

• CARE-PACT requested to see 82 yr old Afghan man,

Aarif, following a fall, he refuses to go to hospital

• His primary complaint is of increasing pain in sacral area

since the fall

• Secondary complaint, reported by RACF staff is of

escalating SOB over past 14/7, despite recent increase

in his frusemide dose

Trigger 1: Medical History from QEII File

• Steroid dependent, rheumatoid arthritis

• Severe ischaemic cardiomyopathy and severe

pulmonary hypertension

• CABG X 3 in 2009 – now diffuse disease in grafts

• AICD and PPM, 2014

• Worsening renal function

• 2 admissions last 6/12 – post discharge did not return to

baseline functioning

Trigger 2: Marlize Jansen,

Assistant Clinical Manager

• Aarif’s history:

– Ex-university lecturer

– Tortured by ruling regime, wife and brother killed

– Private man, afraid of authority and disclosing

personal information (e.g. rips up letters after

receiving them)

– 2 children – daughter in Brisbane (close),

son in Melbourne (estranged)

– Has refused advance care planning (ACP) invitations,

no legal documentation re: ACP

Trigger 3: Dr Chris Tabinga, 3 months later

• Aarif febrile, disorientated, urinary frequency and

incontinence

• Urinary dipstick – RBC+++ and neutrophils+++

• Refuses hospitalisation

Trigger 3: Next day

• Dr Tabinga visits en route to surgery

• ICD fires

• Transfer to PAH, ICD fires 3 more times over 4/7

• Aarif wants ICD turned off, cardiologist says no, akin to

euthanasia

• Has MI while in-patient, renal functions and cardiac

parameters worsening

• After stabilised Aarif discharged back to RACF

Trigger 4: Mia Taylen-Smith

• You organise case conference. On the day Dr Tabinga

sick, cannot attend

• Aarif, never wants to go back to hospital, “not while I

have breathe in my body”

• Wants ICD de-activated

• During case conference, fights with son and leaves,

“talk to my daughter”

• Daughter says culturally appropriate to respect his

decisions

Trigger 5: Jenny Jones, Clinical Ethicist

• We know Aarif has capacity and, according to

Queensland legislation, adults have the right to refuse

treatments.

• What are some of the ethical issues we are faced with

here?

• What will you say?

Trigger 6: Dr Mark Deuble

• That night Aarif becomes unresponsive, breathing

laboured and erratic - ICD firing episodically

• Son says:

– “My father is a fighter, you should not give up”

– “He has been sicker than this before and got better”

– “In my country we treat sick people, not kill them”

• Daughter says:

– “Keep him comfortable, let him die in his home”

• What to do?

Trigger 1 : Medications

• Warfarin 1-2mg

• Digoxin 62.5mcg

• Amiodarone 100mg

• Frusemide 80mg mane, 40mg MD

• Spiranolactone 25mg

• Perindopril 2.5mg

• Omeprazole 20mg bd

• Paracetamol 1g qid

• Ergocalciferol 25mg bd

• Prednisolone variable dose