1. CASE REPORT ESCALATION OF SUPPORT IN DCD PATIENT Dr Peter C Matthews Consultant Intensivist CLOD - Morriston Hospital

2. Presenting Complaint 48 year old man Admitted to Singleton with: general decline in health not eating or drinking significant weight loss multiple ulcers Transferred to HDU falling GCS marked lactic acidosis

3. Past Medical History PTSD former prison officer Occipital CVA seizures Ex alcoholic Partial gastrectomy 2010 for pyloric stenosis Degenerative spinal disorder Pneumonia 2012 ventilated in ITU (tracheostomy) Recent klebsiella pneumonia with lung abscess

4. Immediate Management Treatment by physicians for sepsis 2 0 cellulitis Intubated and invasive monitoring sited Seen by Consultant Intensivist CT head - old changes LP - NAD Empirical broad spectrum cover including anti-virals Transfer to Morriston ITU

5. On-going management Nutritional support oedema +++ with low albumin ? pellagra CT abdomen some abdominal tenderness citrobacter from blood cultures Treatment for bone marrow depression thrombocytopenia anaemia HIV, Hep screen, TSH Vasopressor for hypotension

6. Progress Extubated after 6 days Vasopressors off ECHO EF10% Re-intubated day 7 syphilis test clostridium difficile testing (diarrhoea ++) - negative Limitations discussed with family DNACPR not for RRT not for CVS support

7. Progress Deterioration day 11 hypotensive increasing acidosis oliguria decreased GCS Active withdrawal of treatment planned SNOD informed case discussed with HM Coroner wife given permission for donation to proceed SNOD asked ITU associate specialist if happy for vasopressor to be started to improve organ function and permission given ventilator settings also adjusted by ITU nurse

8. Unexpected Sequelae Patient’s condition improves by the next day (day 12) acidosis improving urine output improving GCS better and some appropriate responses documented discussion between Consultant Intensivist and ACD for ITU to restart active treatment inform family that donation no longer being planned due to unexpected improvement in patient’s condition Consultant Intensivist concerned about the short and long term consequences of the treatment escalation and discusses it with the SNOD

9. Subsequent Events Period of stability followed by another deterioration unable to wean ventilation profoundly weak intermittent hypotensive episodes After discussion with family day 16 end-of-life pathway WLST (extubation) Discussion at a meeting of Consultant Intensivists IR1 form submitted Escalated to IR4 - on-going investigation

10. Discussion