What should a doctor do when a 60-year-old patient with diabetes (diabetic) is in a coma due to diabetic ketoacidosis and has a gangrenous foot, but the patient's family refuses a life-saving amputation?

From the Guidelines

The doctor should seek a court order to proceed with the amputation, as it is a life-saving procedure that outweighs the family's refusal based on cultural or religious beliefs. In this scenario, the patient's life is at risk due to diabetic ketoacidosis and a gangrenous foot, which can lead to fatal septicemia if left untreated 1. The family's decision to prioritize the patient's burial with all body parts intact over their survival is not in the patient's best medical interest. As the patient is unconscious and unable to make decisions, the physician's primary duty is to act in their best interest and preserve their life.

The presence of a gangrenous foot and the risk of septicemia necessitate immediate medical attention, and amputation is a medically necessary procedure to prevent further complications and death 1. The court order provides a legal framework for the physician to proceed with the amputation, balancing the respect for cultural or religious beliefs with the ethical obligation to preserve life.

Key considerations in this case include:

• The patient's life is at risk due to a gangrenous foot and diabetic ketoacidosis
• The family's refusal of a life-saving procedure contradicts the patient's best medical interests
• The physician's primary duty is to act in the patient's best interest and preserve their life
• A court order can provide legal authorization to override the family's objections and proceed with the amputation.

In accordance with the principles outlined in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections, clinicians should prioritize the patient's overall wellbeing and take prompt action to address the infection and prevent further complications 1. In this case, seeking a court order to proceed with the amputation is the most appropriate course of action to ensure the patient's survival and wellbeing.

From the Research

Medical Emergency and Treatment

• The patient is in a coma due to diabetic ketoacidosis and has a gangrenous foot, which is a life-threatening condition 2, 3, 4.
• The doctors have decided to amputate the foot as soon as the patient is stabilized enough to withstand anesthesia, which is a common treatment for gangrene 5.
• However, the patient's family is refusing the operation, citing cultural and religious reasons.

Ethical Considerations

• The doctor is faced with an ethical dilemma, where they must balance the patient's right to life with the family's wishes 6.
• The patient's condition is critical, and delaying treatment could result in fatal septicemia 3, 4.
• The doctor must consider the patient's autonomy and best interests, as well as the family's concerns and values.

Possible Courses of Action

• The doctor could respect the family's wishes and not perform the amputation, which could result in the patient's death 2.
• The doctor could seek a court order to override the family's decision and perform the amputation, which could be a lengthy and uncertain process.
• The doctor could report the situation to the authorities, such as a hospital ethics committee, to seek guidance and support 6.
• The doctor could try to persuade the family to change their decision, by explaining the risks and benefits of the treatment and the potential consequences of not treating the patient 3, 4.
• The doctor could perform the amputation anyway, citing the patient's best interests and the need to save their life, which could be a controversial and potentially legally risky decision 5.