MSGM Clinical Case Discussion June 2026

The Upholding of the No- A broken toenail to the end of life

Prepared by: Navena Sharma

Supervisor: Dr Yusliza Azreen

Case Summary

Madam M, a 71 year old lady with diabetes mellitus, hypertension, and significant vascular comorbidities, had a history of right below knee amputation (2020) and lacunar infarct (2022) without residual neurological deficit; clinical frailty scale of 6. Wheel chair bound since her amputation, she required assistance with transfers and showering but remained fairly independent with dressing, eating and toileting. She lived with her husband, an army pensioner, and her youngest son, with six children in total.

Her medication list includes:

(assisted administration by family)

T Lasix 40mg OD

S/c Actrapid 18u tds

S/c Insulatard 20u ON

T Perindopril 8mg OD

T Prazosin 2mg tds

T Metoprolol 100mg BD

T Amlodipine 10mg OD

T Atorvastatin 40mg ON

T Plavix 75mg OD

T Mecobalamin 500mcg OD

T Bisacodyl 5mg BD

She presented to ETD with worsening left foot pain and fever following toenail trauma and removal, with examination revealing cellulitis and laboratory findings of leukocytosis, elevated CRP, and acute kidney injury. She was admitted for IV antibiotics and the initial days showed improvement over her foot with the appearance of wrinkling sign and subsiding erythema. In the following days of her hospitalization, she endured stormy episodes of lower gastrointestinal (GI) bleeding from hemorrhoids, fluid overload due to overzealous fluid resuscitation which subsequently led to pneumonia, pulmonary embolism requiring anticoagulation; further complicated with upper GI bleeding attributed to duodenal ulcers and worsening renal function. Her left foot infection progressively worsened with hemorrhagic blisters, necrotic changes, absent distal pulses, and features consistent with necrotising fasciitis, prompting consideration of below knee amputation, which patient strongly refused despite persuasion from her family to go ahead with the intervention.

Psychiatric evaluation identified major depressive disorder (MDD) with persistent depressive disorder (PDD) features, longstanding since her prior amputation, with passive death wishes and hopelessness. She was deemed to have valid decision making capacity under the Mental Health Act (2001) with her refusal for surgical intervention. She expressed her wish to go home but her son needed time to discuss with the rest of the family to take her home. Palliative care was initiated in accordance with her wishes, though her family persistently advocated for surgery. As her condition worsened with delirium and sepsis, her husband requested to override her decision and proceed with surgery. By then she had deteriorated further and deemed unfit for the procedure. End of life care was optimized, and Madam M ultimately succumbed to her illness in the hospital, surrounded by family, with her autonomy and decision against surgery respected.

In this poignant and ethically dense case, Madam M’s journey sits at the intersection of geriatric complexity, psychiatric vulnerability, and the legal "gray zones" of end-of-life care.

Discussion Points

1. The Dark Pit: Depression and Capacity

Madam M was diagnosed with MDD and PDD. In general, we often mistake the quiet patient for the compliant patient.

The Point: Can a patient with MDD truly provide a valid refusal, or is the refusal a

symptom of hopelessness?

Discussion: The Psychiatry consult was crucial here. Depression does not automatically render a patient incompetent. If the patient understands the consequences (death) and can weigh the options, his/her refusal is valid. The psychiatrist actually validated her by confirming that her sadness did not negate her sovereignty.

Reference:

o Hindmarch T, Hotopf M, Owen GS. Depression and decision-making capacity for

treatment or research: a systematic review. BMC Med Ethics. 2013 Dec 13;14:54. doi:

10.1186/1472-6939-14-54. PMID: 24330745; PMCID: PMC4029430.

o Robbins-Welty G, Strong C, Briscoe J. Understanding the Influence of Depression on Decision-Making Capacity at End of Life (TH123C) Journal of Pain and Symptom Management, Volume 65, Issue 5e520-e521May 2023

2. The Fluctuating; Shield: Autonomy vs. Delirium

The most intriguing moment in this case is the husband’s request to override Madam M’s refusal once she became delirious; Waiting for Delirium Strategy.

 The Point: Does a patient’s Right to Refuse expire the moment he/she loses capacity? Is it ethical to wait for a patient to lose capacity so a kinder; decision can be made by a proxy? When a spouse overrides a previously competent refusal, is it an act of love, or an act of identity theft?

 This may also represent the Infantilization of the elderly. The system often treats the spouse as the owner of the patient’s body once the patient can no longer speak.

 When the husband tried to override her, he was acting as a Proxy, but proxies are generally meant to enact what the patient would want, not what the proxy wants. This is the Substituted Judgment Standard.

The Legal Reality: Section 77(5), Mental Health Act 2001 (Malaysia)

 The law clarifies that if a patient is capable of giving (or withholding) consent, that consent is valid. The family’s keenness for surgery does not grant them the right to perform substituted judgment that contradicts a known, competent refusal.

 Discussion: Legally and ethically, a competent refusal made prior to losing capacity (Anticipatory Refusal) should remain valid. This is often referred to as Precedent Autonomy. The law essentially says: A No spoken in the light of day cannot be ignored just because the patient is now in the dark of delirium.

 Reference:

o Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007 Nov 1;357(18):1834-40. doi: 10.1056/NEJMcp074045.

o PMID: 17978292. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010 Apr 1;362(13):1211-8. doi: 10.1056/NEJMsa0907901. PMID: 20357283; PMCID: PMC2880881.

3. The Family Burden: Beneficence or Projection?

The family's eagerness for surgery vs. the patient's refusal highlights the Cultural vs. Legal divide.

The Point: In many Asian contexts, Family Autonomy often supersedes Individual Autonomy.

Discussion: The son’s need for more time to discuss with siblings regarding bringing patient home as expressed by herself reflects the collective decision-making model. However, the medical team’s role is to protect the patient from non- beneficence—subjecting a frail 71-year-old to a high-risk amputation that she explicitly did not want.

Reference:

o Hattori K.East Asian Family and Biomedical Ethics. Chapter 7 (7.3). Asian Bioethics in the 21st Century (2003). Song Sang-yong, Koo Young-Mo & Darryl R.J. Macer (editors).

o Tai MC, Tsai TP. Who makes the decision? Patient's autonomy vs paternalism in a Confucian society. Croat Med J. 2003 Oct;44(5):558-61. PMID: 14515413.

4. The Iatrogenic Cascade: A Geriatric Cautionary Tale

Madam M's complications (fluid overload; infection-- PE --UGIB) "illustrate the iatrogenic overzealousness of a clinical assembly line."

The Point: We often view omission of care as a failure, but in geriatric medicine,

commission of care can be the perpetrator. Every intervention for a frail elder carries a hidden tax.

Discussion: Was the aggressive treatment of her cellulitis the trigger for her demise? At what point does IV therapy and anticoagulation stop being the treatment and start being the assault on a failing physiology, ignoring the fragility of the vessel? When should we pivot from Cure to Care?

Reference:

o Roller-Wirnsberger R, Thurner B, Pucher C, Lindner S, Wirnsberger GH. The clinical and therapeutic challenge of treating older patients in clinical practice. Br J Clin Pharmacol. 2020 Oct;86(10):1904-1911. doi: 10.1111/bcp.14074. Epub 2019 Aug 6. PMID: 31321798; PMCID: PMC7495268.

Conclusion- The silent refusal

Madam M did not depart because her family failed to save her, nor because the doctors failed to cut. She departed this life because she had reached the end of her endurance, a boundary she had clearly demarcated when she was still of sound mind; despite her family’s desperation of preservation, and the hospital, adhering to the rigidity of protocol, asking her to live on terms she had already rejected.

In upholding her refusal, even when she could no longer voice it, the medical team provided the ultimate geriatric-palliative service; the preservation of dignity over the mere preservation of biology. It was a final, quiet victory of a woman who refused to be overruled by the very people and systems that were supposed to protect her. She leaves behind a legacy that screams just how vital advance care planning (ACP) is for every one of us; a fundamental right to one’s own narrative.