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Background and Aims Informed consent forms the cornerstone of regional anaesthesia. In patients lacking mental capacity, risks of a performing a particular regional technique/alternatives would not be able to be conveyed. The decision to use regional techniques may make anaesthetists uncomfortable especially if the incompetent patient has no family members/legal representatives. This poster suggests using Jonsens’s 4box approach(1) to aid anaesthetists’decision-making/justification when using regional techniques in sub-optimal patients.

Methods 85 year old severely demented Mr.X, bedbound, was from state-run nursing home for destitutes. He was admitted with wet gangrene of right forefoot,in severe distress. He developed a sepsis-related myocardial infarction needing dual anti-platelets(clopidogrel,aspirin). A debridement/toes amputation was planned,under popliteal/saphenous nerve block,despite his coagulopathic state.

Results Box1:Medical indications. To remove source of sepsis and pain relief, without general anaesthetic risks. Box2:Patient preference. Would he want surgery under regional block when coagulopathic, with complications such as haematoma/nerve injury? Lacking capacity and needing urgent procedure, the anaesthetist made decisions based on best interest/neccesity. Box3:Quality of life. His premorbid state was miserable but his current state worse as he was in pain and septic. Box4:Contextual features. There was no dignity having a smelly/painful septic gangrenous foot. Regional technique was safer than general anaesthetic in view of his recent infarction. Not without risks, the peripheral nature of the block and using ultrasound guidance made it safer.

Conclusions The four box approach was used to guide decision to perform a nerve block in a coagulopathic patient, who was unable to discuss risks and alternatives. The over-riding consideration acutely was his dignity, comfort.

Attachment AbstractJonsen AR.docx