PIG Meeting: 29th April 2021

53-year-old lady for cystoscopy and intravesical botox for urge incontinence

• BMI 48
• COPD. Current smoker. 40 pack years
• PFTs showed normal lung volumes but reduced TLCO (likely in keeping with her known pulmonary hypertension)
• NIDDM. Poor glycaemic control. HbA1c = 9.9%
• HFpEF and moderate pulmonary hypertension
• Uncontrolled hypertension
• Non-obstructive CAD
• T-cell lymphoma – currently in remission since chemotherapy and stem-cell harvest but moderate prognosis disease with 43% 5-year mortality rate
• Extremely poor exercise tolerance, resting every 10-20 steps
• NASH

Issues

• Consult in clinic and advised on multiple areas for optimisiation including.
  • Weight loss and dietician via GP
  • Smoking cessation
  • Diabetes optimisation
  • Sleep studies

• Patient had pursued none of these recommendations, citing social stressors.
• Surgeon contacted to request a further 3mth delay.
• Surgeon decided to cancel the procedure, believing conservative measures were more appropriate and that her other health problems were far more important to optimise.

Discussion

Was this the right decision?

• Should we be more compassionate regarding the contribution of her social stressors to her health inertia?
  • Is an incontinence procedure likely to be effective in a morbidly obese smoker? Thought to be low value healthcare.
  • Could this procedure be done under LA (group consensus was no, based on previous experience).
  • Is this paternalistic?
  • Possible that the surgical team requested a ‘consult’ in the hopes that we would say no?

• Ideally the decision to cancel should have been communicated by the surgical team, rather than via periop clinic.
• A letter was sent to the GP which clearly outlines ownership of the decision.