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Consent, capacity and the right to say no

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Case study

A 74-year-old Sicilian woman was admitted to hospital with stridor and dysphonia in the setting of concurrent upper respiratory tract infection. This was on a background of toxic multinodular goitre that had been treated for 8 years with propylthiouracil, as she had reacted adversely to carbimazole. She had been recommended surgery in the past, but had declined.

Clinical examination revealed an obvious stridor and a diffuse, symmetrically large goitre. Pemberton sign was positive. Thyroid function tests had demonstrated a suppressed thyroid-stimulating hormone level (0.03 mU/L; reference interval [RI], 0.5–4.0 mU/L), with a free thyroxine level within the RI (16.3 pmol/L; RI, 10.0–19.0 pmol/L). Ultrasound and computed tomography imaging identified a large, retrosternal, multinodular goitre. Her trachea was significantly compressed, with a diameter of 5.5 mm (Box). We further recommended total thyroidectomy, which she again politely declined.

The night after admission, her condition deteriorated acutely and she was transferred to the intensive care unit with respiratory distress. The need for intubation was avoided and she was sufficiently managed with nebulised adrenaline and intravenous dexamethasone. Again, she refused surgery.

She remained in intensive care for the following week, with extensive discussion involving her family…