Ethics Discussion: Patient Referral & Advocacy

This is a discussion on the ethical dilemma of a family physician / general practitioner registrar:

I am currently rotating through the adult clinical and I found this situation that got me thinking on what the role of a family physician could be in such scenario and how much of patient advocacy would be required.


Patient is 72 years old. Let’s call her Mrs Y. She had multiple comorbid conditions – hypertension, diabetes mellitus, dyslipidemia, peripheral vascular disease, chronic kidney disease and generally poor baseline.

She presented with critical limb ischaemia and was clinically septic. Her kidney function had also rapidly declined in the course of her illness. Her blood sugar fluctuated between very high and very low. 

She presented acutely ill, and her ill health had significantly impaired her autonomy. She however had the support of her family. 



Critical limb ischemia with sepsis, with the background of the above-named comorbidities. Acute on chronic kidney disease. For urgent surgical/medical intervention.


Elderly, frail, with impaired autonomy.


Support of friends and family who wanted the best care for her.

Plan/Further intervention:


Patient needed urgent vascular surgery, but following discussion with the surgeons, she did not qualify for further interventions such as vascular surgery or amputation due to factors such due to age and overwhelming medical conditions.

Patient was thereafter referred to adult medicine but was also rejected as she did not qualify for escalation of care, not for ICU care, not for renal replacement and not for further medical intervention; due to factors such as her age, comorbid conditions, overall clinical state, and an obvious focus of sepsis – leg gangrene which was not for surgical removal.

? For supportive care, e.g. pain management, rehabilitation, and possible discharge to family care or hospice care.

Personal and contextual:

The clinical assessment will obviously have profound impact on what her personal and contextual circumstances going forward, and these will need careful planning with relevant stakeholders. 

Discussion and ethical questions.

It appears Mrs Y has now become one of the “problem patients” for the family physician, as her care plan has now become “palliation” or “supportive”. 

Photo by fauxels on

Several questions arise:

  • How should the family physician manage or support a person who is in constant severe pain, and is septic from the gangrenous leg, and could not be treated by either the surgeons or the physicians due to multiple factors? 
  • Could the family physician advocate further or should he just accept the decisions (made by his colleagues in the other specialties) and just break the news to the patient and family regarding the hopelessness of their situation?
  • Discharging such patient at any point will definitely lead to mortality, and she cannot be kept on the hospital indefinitely.
  • What if the family are willing to take the risk and demand for surgical intervention?
  • Could the family physician pressure further for the surgeons to at least remove the source of the sepsis despite the high risk?
  • What ethical principles could support or reject the decisions by the physicians and the surgeons on this particular patient?
  • The family physician is considered the patient advocate, but obviously this advocacy has limits. can this be justified in this patient scenario?

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