title: What are the ethical issues in treating a patient with bilateral leg gangrene incapable of consenting to amputation secondary to psychiatric illness?
abstract: BACKGROUND
  Bilateral and simultaneous lower extremity amputations unrelated to diabetes and peripheral vascular disease are uncommon, although they may be necessary in patients with severe blast injuries. Such amputations, however, usually are performed in patients who are able to understand and consent to the treatment.
  
  
  METHODS
  We present the case of a 29-year-old woman who experienced drug-induced psychosis and underwent substantial hypothermic injuries; most notably, irreversible frostbite injuries to both lower extremities, leading to dry and mummified gangrene. As a result of her psychiatric illness, fluctuating catatonic state, and lack of insight into her clinical condition, she was deemed incapable of making decisions regarding her medical care and her mother was made substitute decision maker. The orthopaedic service was consulted regarding possible surgical treatment of her gangrenous feet that were stable and aseptic after limb preservation efforts (including hyperbaric oxygen) had been tried without success. They recommended close clinical monitoring and continued psychiatric treatment. The family, including the substitute decision maker, citing the patient's best interest, rejected the recommendations of the surgical team and demanded immediate surgical transtibial amputation of both lower legs.
  
  
  METHODS
  To our knowledge, such a unique case has not been reported.
  
  
  CONCLUSIONS
  We examined the decision-making process, the difficulties of caring for such a patient, and the ethical issues that arose.
authors.affiliation: Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada. Taylorm1@kgh.kari.net.|Kingston General Hospital, Kingston, ON, Canada. Taylorm1@kgh.kari.net.
authors.forename: Michel
authors.initials: M
authors.lastname: Taylor
authors.affiliation: Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.|Hotel Dieu Hospital, Kingston, ON, Canada.
authors.forename: Douglas
authors.initials: D
authors.lastname: McKay
authors.affiliation: Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.|Kingston General Hospital, Kingston, ON, Canada.
authors.forename: Moustafa
authors.initials: M
authors.lastname: Eid
authors.affiliation: Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
authors.forename: Udo
authors.initials: U
authors.lastname: Schuklenk
authors.affiliation: Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.|Kingston General Hospital, Kingston, ON, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Pichora
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000941:ethics* / Q000523:psychology*; D002755:Choice Behavior; D019970:Cocaine-Related Disorders / Q000150:complications / Q000175:diagnosis / Q000523:psychology*; D005260:Female; D005627:Frostbite / Q000150:complications* / Q000175:diagnosis; D005734:Gangrene; D006801:Humans; D007869:Leg Injuries / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D016743:Mental Competency / Q000523:psychology*; D011605:Psychoses, Substance-Induced / Q000150:complications / Q000175:diagnosis / Q000523:psychology*; D020458:Third-Party Consent / Q000941:ethics*