Four

days after admission, Mr MF’s cardiologist transferred him to CCU to optimize his cardiac management. Mr MF informed the renal team that he wished to stop dialysis and his wife agreed, stating PD332991 that her husband had discussed this during his last brief time at home. The renal team doubted Mr MF had the capacity for decision making and asked a psychiatrist to give a second opinion. The cardiologist was uncomfortable with the patient’s decision and asked Mr MF to continue dialysis until the anti-depressants became effective. Mr MF requested his decision be respected. Mr MF’s wife accused the cardiologist of bullying her husband into ongoing dialysis. The cardiologist noted a potential conflict of interest because Mr MF’s wife had previously divulged to him that Mr MF was physically and verbally abusive towards her. Mr MF’s family articulated distress at a family meeting with the renal and cardiac teams that his wishes were not being respected and he was being forced to dialyse. All agreed to await the outcome of the second opinion of Mr MF’s capacity to make decisions about end of life. Mr MF was not present at the family meeting. Mr MF

was deemed capable of EOL decisions by a consultant psychiatrist. The three medical teams – renal, cardiology and psychiatry – met with the hospital solicitor because the cardiologist was uncomfortable with the decision to withdraw dialysis. The meeting reached a consensus of EOL care without dialysis and the renal team spoke to the patient about cessation of dialysis. Mr MF was referred to the consultative palliative care team and was Selleck Galunisertib subsequently transferred from CCU to the Renal Ward. The cardiologist remained distressed and asked the patient and

his wife to sign acknowledgement of refusal of medical treatment. The renal inpatient team and palliative care consulting team initiated the care of the dying pathway and Mr MF died peacefully shortly after with his family in attendance. The family sent a letter to the renal team a week later thanking them for caring for Mr MF. This complicated medical case was compounded by distress in the aminophylline healthcare team. Members of the team disagreed about treatment plans and the boundaries of the patient’s autonomy. The distress could not be resolved despite wide consultation with colleagues and legal involvement. This case demonstrates a number of problems frequently encountered by nephrologists Advance discussions with nephrologists prior to procedures.  This patient would have benefited by seeing a nephrologist before the renal artery angioplasty was attempted, allowing discussions of likely outcome and complications. The history suggests that the procedure was being attempted to reduce episodes of APO. This patient was known to have cardiac disease with ongoing angina and a blocked coronary stent. He therefore has potential mechanisms for pulmonary oedema unrelated to his renal arteries and thus raises the question of whether this procedure could be effective.