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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. |
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Cases: 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. |