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