Doctors do not have to amputate an elderly man’s leg against his wishes, even though he may die if the leg is not removed, the High Court has ruled.
The President of the High Court made the decision in a case he described as posing an “appalling dilemma” for the medical staff involved.
The court ruled that it was lawful for medical staff in a hospital in the west of Ireland to provide all necessary care and medical treatment to the man, who also suffers from dementia, but that doctors could stop short of amputating his leg as he has clearly expressed the view that he would rather die than lose his leg.
Mr Justice David Barniville said this was a very difficult conclusion for him to draw. But he said he felt he had little alternative in light of the evidence he had heard.
The court heard the man, who is in his 70s, lives in a remote location but has been in hospital since the middle of last year.
He suffers from severe peripheral vascular disease as a consequence of poorly controlled type two diabetes and when first admitted to hospital he was at imminent risk of losing one of his legs.
Doctors carried out surgery to put a graft on his leg and managed to save the limb but the court heard the man has interfered substantially with his wound.
Barrister Donal McGuinness, on behalf of the HSE, said the man suffers from delirium as part of his dementia and had put jam and hot drinks on the wound.
It is now infected and the man’s leg is considered unsalvageable by doctors.
He said the man was at risk of a haemorrhage when the graft inevitably broke down.
However, he said the man had consistently and persistently refused to consent to the amputation, even when he was told he was at risk of bleeding to death if he did not have the leg removed.
He has told doctors that if he died, he died.
He said “you may as well throw me in the sea” and described having his leg amputated as “an effing crazy idea” because “you need two legs to walk”.
Mr McGuinness said the man’s family were in favour of having the amputation done and the court heard they were unwilling to take him out of hospital at the moment because of the risk of a catastrophic bleed.
Mr McGuinness said the HSE was asking the court to make a declaration that giving the man all necessary care but stopping short of amputating the leg, was lawful.
The consultant vascular surgeon in charge of the man’s care described the situation as “very difficult” and said the man could swing from “normality, to delirium, to confusion, to dementia in the same minute”.
He said it was a “no win situation”.
From a clinical perspective, the doctor said, amputation was clearly indicated but the patient had insisted very clearly that he would rather die.
The medical staff were trying to respect the man and give him dignity in his choices, he said.
He said that vascular doctors had a saying “life over a limb, not a limb over a life” but in this case the man had decided his life had no value without his leg.
The court was told the man was not in pain and had expressed the view that he might change his mind about the proposed amputation if he began to suffer “horrible” pain.
The court also heard that if his leg was removed he would not be able to walk again as his physical frailty and cognitive impairment would make it very challenging to use a prosthesis.
He would be unlikely to be able to return to his home.
The consultant geriatrician dealing with the man’s case said doctors had agonised a great deal over the man’s case.
The man would probably suffer from post operative delirium if the operation went ahead and it would not be fair to try and get him mobile again, he said.
He said the man was also likely to suffer from very genuine anger, upset and bewilderment if he came around from an anaesthetic to find his leg suddenly gone.
He said clinically, amputation would be the best thing for the man but taking everything else into account, amputation may be the wrong thing for him.
The man might live longer if his leg was amputated, the doctor said but the overall degree of psychological distress would be enormous and it might negatively impact the quality of the life he had left.
The guardian ad litem appointed by the court, James Bardon, travelled to meet the man at short notice in order to be able to report to the court.
Mr Bardon said the man had told him he was vehemently opposed to the amputation of his leg. He said even though the man lacked mental capacity, his wishes were very, very clear. Mr Bardon said he would, however, like an opportunity to discuss the matter with the man’s family.
Mr Justice Barniville said he would give his ruling immediately as it was quite clear doctors needed an answer as to whether what they had proposed was lawful.
He said the doctors and medical team had been placed in a dreadful dilemma.
It was very clear the man needed the amputation to survive, but it was also his clearly and strongly expressed wish that he did not want his leg amputated.
Taking a strictly medical approach was problematic, the judge said.
It would solve the medical crisis but was likely to create a significant disturbance to his mental wellbeing.
The judge said the evidence showed the man attached great importance to being mobile and went up and down the hospital corridor 20 to 30 times a day on a zimmer frame.
If he came out of surgery to discover his leg was gone, there would be appalling consequences for him.
The judge said the evidence on the man’s capacity to make decisions was not clear cut or beyond doubt.
But he said in this very difficult case, he had decided he should accede to the HSE’s application and grant the declaration allowing doctors to take all measures short of amputating his right leg, because of the man’s clearly expressed wishes, in spite of medical advice to the contrary.
The matter will be back in court on 5 May. Mr Bardon undertook to provide copies of the court papers to the man’s wife and son.
Court rules man’s leg does not have to be amputated
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