Background

• 79M for colonoscopy – previous positive FOBT, subsequent negative FOBT. Asymptomatic. Not anaemic.
• Acquired brain injury, limited understanding, difficult historian
• OSA
• Mod-severe COPD
• AF – on apixaban
• Heart failure (NYHA3) – recent admission for exacerbation requiring diuresis and fluid restriction
• Most recent echo – moderate diastolic dysfunction, moderate pulmonary hypertension
• Very limited exercise tolerance, limited due to SOB – difficult to quantify precisely due to quality of history.
• Lives alone but has carer 3 times weekly

Issues

• Appropriateness of proceeding: Similar to previous case, high risk/complex patient in terms of heart failure and cognitive limitations – should we proceed with colonoscopy?
  

Discussion

• What is the likelihood of intervention if cancer was found? More likely to be offered surgery than previous patient. And may prevent presentation with more advanced pathology down the track which would make intervention worthwhile. Discussion around life expectancy of patient and the fact that clinician prediction of life expectancy is very poor and limited models exist for prediction of life expectancy.
• What is the appropriateness of FOBT in this population? Pre test probability for this patient is low. 
• Discussion regarding low value healthcare involving low yield or futile therapies with minimal change to QOL in last years of life. 
  

Plan

• For CT colonography in the first instance.
• Would be reasonable to proceed with colonoscopy if indicated.
• Would likely need supervision for bowel prep given cognitive impairment and heart failure.