Controversy and consent: achieving patient autonomy in thrombolysis for acute submassive pulmonary embolism

Acute pulmonary embolism (PE) is associated with a wide variation in patient outcome ranging from completely asymptomatic to cardiac failure and death. This presents a challenge to clinicians in ensuring the correct treatment for individual patients is given and that adverse events secondary to treatment complications are minimised. The evidence for those with massive PEs and non-massive PEs is clear for and against the use of thrombolysis, respectively. However, in those with 'sub-massive' PE there is no clear consensus on whether there is a treatment benefit. We present the case of a patient who presented with a non-haemodynamically significant PE but with evidence of right ventricular dilatation, and discuss the difficulties in treatment decisions in such cases, including the ethical and legal principles of consent, and how clinicians might best allow their patients to make informed decisions when in clinical equipoise.