The Joint Annual Scientific Meetings of the Endocrine Society of Australia and the Society for Reproductive Biology 2018

Ethical medico-legal and practical considerations for management of hyperthyroidism in the uncooperative patient two case reports (#220)

Kathy Fu 1
  1. Prince of Wales Hospital, Randwick, New South Wales, Australia

Background: Treatment of hyperthyroidism in an unwilling patient is challenging. For those who lack capacity to make medical decisions, urgent and life-saving treatment can be provided under the principle of duty-of-care. For ongoing or major treatment, consent can be sought from next-of-kin or the Guardianship Tribunal. Carbimazole and propylthiouracil are available only in enteral formulations but can be given rectally. Definitive treatments usually result in hypothyroidism requiring lifelong levothyroxine supplementation; there are case reports of successful weekly intramuscular administration1,2. Treatments aiming for euthyroidism, including partial thyroidectomy or low dose radioactive iodine have unpredictable outcomes3.


An 80 year-old lady with chronic schizophrenia was admitted with rapid atrial fibrillation and thyrotoxicosis due to Grave’s disease. She had long-term refusal of antipsychotics and rigid delusions of poisoning. She was scheduled as mentally ill under the Mental Health Act and assessed as lacking capacity to refuse medical treatment. A Guardian was appointed for substitute decision-making, with specific provision for covert and coercive treatment. A combination of oral propylthiouracil hidden in foodstuffs, and per-rectal propylthiouracil under restraint was administered to achieve euthyroidism. Subsequently, a subtotal thyroidectomy resulted in permanent mild-to-moderate hypothyroidism. The patient continues to refuse levothyroxine replacement, but is living independently in the community.

A 32 year-old prison inmate presented with thyroid storm. Due to extreme aggression he was sedated, with prophylthiouracil and other supportive medications administered via nasogastric tube. Corroborative history revealed a background of Grave’s disease, antisocial personality, traumatic brain injury, and longstanding refusal of all oral medications. He required prolonged intubation and sedation, with attendant complication of ventilator-associated pneumonia. Definitive treatment options were explored including radioactive iodine and surgery; finally consent for a hemi-thyroidectomy was obtained through an emergency hearing of the Guardianship Tribunal. Post-operatively, he continues on oral carbimazole voluntarily with marked improvement in aggressive behaviour. 

  1. 1. Anderson, L, Joseph F, Goenka N, Patel V. Isolated Thyroxine Malabsorption Treated with Intramuscular Thyroxine Injections. Am J Med Sci. 2009; 337:150-
  2. 3. Al-Adhamim A, Snaith A, Craig W & Krukowski Z (2013).. Changing trends in surgery for Graves’ disease: a cohort comparison of those having surgery intended to preserve thyroid function with those having ablative surgery. Journal of Otolaryngology - Head and Neck Surgery 42:37
  3. 2.Kalathil D, Rajeev S & Chattington P. Hypothyroidism treated with intramuscular thyroxine injections. Endocrine Abstracts (2012): 28 P359