Tuesday, May 09, 2023

High Court reporters

It would be “enormously distressing” for a man with dementia to discover afresh each day that his leg has been amputated against his wishes, if the High Court orders the surgery should be carried out.

That was a submission made to the court by the man’s consultant geriatrician who has concerns the short-term memory loss will mean the man wakes up “each morning to find that his leg is gone”.

Facing the scenario “anew over and over” could cause post-traumatic stress disorder that goes beyond depression, the doctor said.

The geriatrician does not believe the man has capacity to determine the pros and cons of amputation, but he has been resolutely “vehement” in expressing his desire to keep the leg. It was his view that amputation should not take place due to these welfare concerns.

Last month the court ruled the above-knee amputation did not have to proceed, even though the man might die due to infection of the limb.

However, the matter returned before the President of the High Court on Tuesday as a “divergence of views” had emerged between treating doctors since the case was last in court.

Infection ‘time bomb’

A consultant vascular surgeon told the court the man’s condition has changed and there was now a bigger risk of him bleeding to death. A nursing home would be unwilling to take him because the infection on his leg is a “time bomb” that could “rupture at any time”.

The graft will inevitably break down and the patient, who is in his 70s, could die within 20 minutes if a haemorrhage occurs, the court heard.

The surgeon believed the surgery should proceed. He said the doctors agree the man lacks capacity, but they need guidance from the court as to the best way to treat him.

The man suffers from peripheral vascular disease due to poorly managed type two diabetes. When he was admitted to hospital in mid-2022 he was immediate risk of losing his leg.

Doctors conducted surgery to put a graft on the leg, managing to save it, but the man has since damaged the wound by putting marmalade and hot drinks on it.

The man addressed the High Court President, Mr Justice David Barniville, via video link from his hospital bed on Tuesday. The leg was “a bit sore” but the doctor was not going to take it off, he said.

There is “no point going around on one leg. I want to have the two legs on,” he said. Asked by the HSE’s barrister, Donal McGuinness, if he was scared about a potential amputation, the man said he “would be afraid”.

A consultant psychiatrist who specialises in working with older people said the man is “absolutely adamant” that life isn’t worth living without his leg. He is “such a character” and “strong-minded”, she said, and his vehemently expressed view that he needs his leg is a “very convincing factor” for the court to consider.

In these circumstances, she would prefer a palliative approach over surgery. The man’s family favours the surgery going ahead and believes he could be resilient enough to overcome it.

Mr Justice Barniville said on Tuesday this is “certainly one of the most difficult cases that a judge can be asked to decide”.

He wanted the HSE to provide him with more evidence on Thursday regarding what palliative treatment plan the man would receive in the event the judge orders that the leg is not to be amputated.

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