Case 19 An irregular presentation

Mavis Dixon is an 84-year-old lady with advanced dementia, who is admitted from her care home late one Sunday evening. She is reviewed on admission by Dr Ng, the medical FY1 doctor. Mrs Dixon gives no history but seems distressed, shouting out intermittently and being combative with nursing staff when attempts are made to carry out observations or deliver nursing care. The referral letter from the out-of-hours doctor sheds little light on matters (the doctor had never met Mrs Dixon before this evening) and Mrs Dixon’s son (her next of kin) is said to be on holiday in India. The care home’s background information is sparse in terms of medical history – vascular dementia for seven years, hypertension and atrial fibrillation. Mrs Dixon takes donepezil and no other medications.

What are your thoughts about Mrs Dixon’s presentation?

Observations are eventually possible and reveal a blood pressure of 190/80 and a pulse of 120 in atrial fibrillation (AF). Mrs Dixon is apyrexial. Dr Ng tries to examine her but this proves difficult. The chest seems to be clear. There is a murmur consistent with mixed aortic valve disease. The abdomen seems tense but Mrs Dixon resists examination and it is unclear whether there is an element of voluntary guarding.

Dr Ng sends bloods and undertakes a bedside arterial blood gas (ABG) in order to assess baseline haemoglobin and potassium. His working diagnosis is that of urinary tract sepsis. Dr Ng does not think that Mrs Dixon will tolerate either an intravenous or urinary catheter. Intramuscular doses of ceftriaxone and gentamicin are administered. Dr Ng decides that Mrs Dixon ought not to be resuscitated in the event of cardiorespiratory arrest.

What are your thoughts about Dr Ng’s initial management?

Some six hours later, the registrar on duty reviews Mrs Dixon. She remains unwell and agitated. The registrar notes that inflammatory markers are not significantly elevated and questions the working diagnosis of UTI. He telephones the care home and obtains a history of a sudden onset of acute on chronic confusion associated with apparent abdominal pain (Mrs Dixon had been holding her tummy) and two subsequent episodes of loose blood-stained stool.

What is the likely diagnosis?

The registrar further reviews Dr Ng’s notes and happens across the ABG result which had shown a haemoglobin of 12.8 g/dl and a potassium of 4.3 mmol. The gas also demonstrated a pH of 7.28 and a lactate of 7.6 mmol. The registrar quickly makes a diagnosis of ischaemic bowel but Mrs Dixon’s nurse shouts over to him that she has become unresponsive. The registrar assesses Mrs Dixon who has lost her cardiac output. He concurs with Dr Ng’s earlier decision not to perform CPR.

The hospital receives a letter from Mrs Dixon’s son asking how his mother was allowed to die: if she had been diagnosed earlier, would an operation have saved her; and, who made the decision not to resuscitate her and how could they make this decision without reference to her next of kin?

How should the service manager for medicine respond?

Expert opinion

It is likely that the outcome could not have been altered in this case as many surgeons and intensivists would not consider emergency laparotomy as being in such a patient’s best interests, given her significant comorbidity. It seems likely that Mrs Dixon’s son, given his concerns about the resuscitation decision, may think otherwise. However, both decisions – the appropriateness of laparotomy and resuscitation – lie with the professional who might undertake them. With any patient intervention, the professional must be of the view that an intervention may offer the patient benefit (and therefore be in the patient’s interests) and, where the patient is competent, the patient must also consent to the intervention before it can be carried out. If the professional does not consider an intervention to be of potential benefit, then a patient (or their representative) cannot force the professional’s hand into undertaking the intervention.

In this particular case, Mrs Dixon’s diagnosis could have been made a few hours earlier had further efforts been made to obtain a more thorough history. It is difficult for the Trust to defend a situation where a registered doctor had not assessed a patient within six hours of arrival, and where a resuscitation decision is made by a pre-registration doctor without reference to senior colleagues.

The Trust should apologize for the shortcomings in Mrs Dixon’s care but be clear about how decisions about resuscitation and other interventions are made.

Legal comment

It is important that junior doctors are able to escalate decisions with regard to CPR to a more senior colleague in a timely fashion. There is likely to be a Trust protocol or guideline with regard to Do Not Attempt Resuscitation (DNAR) orders outlining the steps that must be taken and the staff who should be involved in the approval of a DNAR order. The Trust is also vulnerable in its position, as there appears to be no documented assessment of the patient’s capacity prior to a best interests decision. It is important at all times, particularly towards the end of life, that decisions as significant as this one are communicated with the next of kin in advance of an emergency situation arising.

Stay updated, free articles. Join our Telegram channel

Join