The High court has again been asked to decide if doctors should amputate the leg of an elderly man against his wishes or risk his death if the surgery is not carried out.
The man, who has dementia and lacks capacity to make an informed decision, addressed the court by video link, telling the judge he "was afraid" to lose his leg.
The case has returned to court after what was described as a "divergence of views" emerging between medical staff since the case was last in court.
Last month, the court ruled the amputation did not have to take place even though the man may die.
However, a consultant vascular surgeon told the court today that the man's condition has changed and there was a greater risk of him bleeding to death suddenly, which meant nursing homes would be unwilling to take him on and there was no firm palliative care plan in place.
The surgeon disagreed with the views of a geriatrician and a psychiatrist who said amputating the leg against the man's wishes would cause him "catastrophic mental distress".
He said it was common to have post-traumatic stress and depression after amputation, but these could be dealt with by medication. He said he was "weighing life over a limb". He also said he believed the man's cognitive function would improve greatly after the surgery as the infection and pain would be eliminated.
The surgeon said the situation was very complicated and they had come to court for guidance as to what was best for the man.
He said the patient being the subject of court proceedings made it very difficult as they were operating in a very "medico legal environment".
The man, who is in his 70s, lives in a remote location but has been in hospital since the middle of last year.
He suffers from severe peripheral vascular disease as a consequence of poorly controlled type two diabetes and when first admitted to hospital he was at imminent risk of losing one of his legs.
Doctors carried out surgery to put a graft on his leg and managed to save the limb, but the court heard the man has interfered substantially with his wound, putting butter and marmalade on it due to his dementia.
It is now infected and the man's leg is considered unsalvageable by doctors.
He said the man was at risk of a haemorrhage when the graft inevitably broke down. Today the court heard if such a bleed takes place, he could die within about 20 minutes.
Mr McGuinness said the man had consistently refused to consent to the amputation, even when he was told he was at risk of bleeding to death if he did not have the leg removed.
Addressing the court by video link from hospital, the man told the President of the High Court, Mr Justice David Barniville, there was "no point in going around with one leg" and that even if he lived longer he "wouldn't be going anywhere".
He told the judge his pain was not too bad at the moment, and he would get back in touch and would think about it a bit longer. He said he was "afraid" to lose his leg.
A consultant geriatrician told the court that the man does not have capacity to weigh up the pros and cons of amputation but had been "clear and consistent throughout" that he was not willing to have his leg removed and had expressed this on both occasions that he spoke to him.
When making a medical decision they had to balance the benefit and the burden of a procedure, he said adding that the burden in this case would be the loss of mobility, the post-traumatic stress and depression the amputation might cause.
From a welfare perspective it was his view that the amputation should not take place. He said the man would struggle with instructions for his recovery due to his dementia. He did not agree that the man's cognitive ability would improve after surgery, adding that it was vascular dementia which was not reversible.
A consultant psychiatrist who specialises in older people said it was her belief that amputating the man's leg against his wishes could cause "catastrophic mental distress" if he believed his wishes had been overruled and he had been ignored.
She said: "This man is such a character, he is a force of nature, and he says what he feels and wants and makes no bones about it. It is important for those of us who work with older people to make sure they don't lose autonomy...just because they have dementia it does not always mean that what you have to say isn't very valid, and even though he doesn't meet the test for capacity, his vehemently expressed view that he needs to have his leg is a very convincing factor to take into account here."
She said being mobile was important to the man and was often a feature of people with dementia who could be restless. She agreed with an occupational therapist report that the man would have difficulty using a wheelchair or prosthetic and for all of these reasons her assessment reluctantly was that she agreed he should not have the surgery.
She said it might also be the case that the man would suffer repeated trauma as he could forget the leg had been amputated and have to be told again and again.
The court heard the man's family is in favour of the surgery, believing he may be resilient enough to overcome it. They were also willing to help with his care should he be discharged from hospital.
Mr Justice Barniville said the case was one of the most difficult types to come before the court. He adjourned the case until Thursday when he will hear further evidence about the availability of palliative care both in hospital and in the community.
