From the Guidelines
The doctor should pursue option E, proceeding with the amputation as it is a life-saving procedure, despite the family's refusal, to prevent fatal septicemia and prioritize the patient's morbidity, mortality, and quality of life. In this critical emergency, the patient's unconscious state and the family's refusal of a medically necessary procedure contradict the patient's best medical interests. Diabetic ketoacidosis with gangrene is a severe condition that requires prompt intervention, as highlighted in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. The guideline emphasizes the importance of evaluating the patient as a whole, the affected foot or limb, and the infected wound, and documenting and classifying the severity of the infection based on its extent and depth and the presence of any systemic findings of infection. Given the patient's condition, amputation is necessary to prevent the spread of gangrene and fatal septicemia, and the doctor's primary duty is to the patient's life and well-being.
The family's concerns about the patient's burial with all parts of their body intact are important, but they should not take precedence over the patient's immediate medical needs. The doctor should document all discussions with the family, the medical necessity of the procedure, and maintain transparent communication throughout the process. Time is critical in this situation, so the doctor should proceed with the amputation while continuing supportive care to stabilize the patient's condition. The guideline recommends assessing the affected limb and foot for arterial ischemia, venous insufficiency, and other factors, which is crucial in this case to determine the best course of treatment 1.
Key considerations in this case include:
- The patient's unconscious state and inability to make decisions
- The family's refusal of a life-saving procedure
- The medical necessity of the amputation to prevent fatal septicemia
- The doctor's primary duty to the patient's life and well-being
- The importance of documenting all discussions with the family and maintaining transparent communication
- The need for prompt intervention to stabilize the patient's condition and prevent further complications, as emphasized in the guideline 1.
From the Research
Medical Emergency and Treatment
- The patient is in a life-threatening situation due to diabetic ketoacidosis and a gangrenous foot, requiring immediate medical attention 2, 3.
- The doctors have decided to amputate the foot to prevent the spread of gangrene and fatal septicaemia, which is a common complication of diabetic ketoacidosis 2, 3.
- The patient's family is refusing the operation, citing cultural and personal reasons, which may lead to a delay in treatment and potentially fatal consequences.
Ethical Considerations
- The doctor is faced with an ethical dilemma, where the patient's life is at risk, and the family's wishes may not align with the best medical course of action 4, 5.
- The doctor must consider the patient's autonomy and the family's wishes, while also ensuring that the patient receives the necessary medical treatment to save their life.
- In cases where the patient is unable to make decisions for themselves, the doctor may need to seek alternative avenues, such as a court order or consultation with an ethics committee, to ensure the patient receives the necessary treatment.
Treatment Options
- Amputation is a life-saving procedure in this case, and the doctor should consider proceeding with the operation to prevent further complications and death 5, 6.
- The doctor should also consider alternative options, such as cryoamputation, which may be used to stabilize the patient before surgical amputation 5.
- Ultimately, the doctor's primary responsibility is to save the patient's life, and they should take all necessary steps to ensure the patient receives the best possible medical care.