Postoperative hypoxia in a woman with Down's syndrome: case outcome

Five weeks ago (9 April, p 834) we presented the case of Miss Webb, a 24 year old woman with Down's syndrome, who developed postoperative hypoxia after a hysterectomy for menorrhagia. She was subsequently found to have a pericardial effusion.

A full blood count done on her second admission showed a high mean corpuscular volume of 109.8 (normal range 80-100) fl. Her liver function results and vitamin B12 and folate concentrations were normal. Thyroid function tests showed a thyroid stimulating hormone concentration of 63.7 (0.5-4.1) mIU/l and free T4 of 2.57 (10.3-25.3) pmol/l. Severe hypothyroidism with multiple serous effusions of the pericardial and pleural cavity was then diagnosed. She was treated with oral levothyroxine (thyroxine) 100 μg per day initially. Intravenous liothyronine 25 μg three times a day was then added to get a prompt response. After five days of intravenous therapy, liothyronine was stopped and oral levothyroxine continued. The pleural and pericardial effusions were fully aspirated.

She made an excellent recovery and was discharged home on a daily maintenance dose of 125 μg of levothyroxine. An echocardiogram at one month did not show any pericardial effusion and her chest radiograph showed no abnormality. Two years later she remains extremely well and independent, with normal thyroid function test results.

Any discussion on this case would be incomplete without commenting on the ethical aspects of the consent process. The box highlights the salient points that were kept in mind when obtaining consent from Miss Webb. She was given all the information about

• The benefits and risks of proposed treatment

• What the treatment involved

• The implications of not having treatment

• What alternatives were available

• The practical effects on her life of having and not having the treatment.

Obtaining consent from people with learning disablilities

• Adults are always presumed to be capable of taking healthcare decisions, unless the opposite has been shown. This applies just as much to people with learning disabilities as to any other adult

• People are not to be treated as unable to make a decision unless all practicable steps to help them do so have been taken without success

• For a person's consent to be valid, the person must be:

  Capable of taking that particular decision (competent)

  Acting voluntarily

  Provided with enough information to enable decision making

• People with learning disabilities will often have support from people close to them (family members, carers, or friends) or from independent supporters or advocates who can help them understand the issues and come to their own decisions

Her mother played an important part in the decision making process. In the end, Miss Webb agreed to a hysterectomy, knowing what the implication of that would be on her future fertility.