The Decision for TIPS for Refractory Ascites: How to Weigh the Social Aspects Involved in Undocumented Patientsʼ Care

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is associated with a number of serious complications and thus necessitates a careful consideration of the risks and benefits to the procedure individualized to each patient. Such assessments usually include relevant clinical characteristics of a patient, but the social dynamics may need to be considered as well. We present the case of an undocumented 45—year—old male with a history of former alcohol abuse and alcoholic cirrhosis (MELD 16, Child—Pugh Class B) who presented with symptomatic massive ascites. One month prior to the admission, the patient's diuresis regimen had been increased to maximum intensity. However, the patient upon admission was unsure whether he had been taking the correctly increased regimen or the prior one. After multiple large—volume paracenteses, the patient expressed that after discharge he would return to his native country in order to be with his family given his relatively poor prognosis. Furthermore, he requested for any definitive intervention that would decrease the likelihood of further episodes of symptomatic ascites, as he did not trust the medical care in his home country. TIPS procedure was considered in order to hopefully provide the patient a resolution to his refractory ascites, though it was unclear whether the patient had truly failed a maximized diuretic regimen. Furthermore, the patient's urinary sodium excretion suggested diuretic sensitivity. Upon suggestion of an appropriate diuretic trial after discharge with subsequent follow up for TIPS consideration as an outpatient, the patient responded that his plan was to leave for his home country immediately after discharge in order to not waste any of his remaining time left with his family. The decision regarding TIPS as an inpatient given the social circumstances despite the ambiguity regarding the patient meeting clinical criteria was deliberated extensively by all providers involved in the patient's medical care. Ultimately, the decision was made to avoid TIPS as an inpatient based on the principle to avoid possibly causing harm to the patient from a complication of a procedure that may not have been medically indicated. Our case demonstrates an ethical dilemma with regard to how strictly medical professionals should abide by criteria indicating when a procedure is necessary. While other providers may disagree, we felt the principle of “Do no harm” prevailed in our estimation of the patient's care.