From the Guidelines
The doctor should prioritize the patient's medical needs and consider legal intervention if necessary to protect the patient's best interests, as the refusal of a life-saving amputation due to diabetic ketoacidosis (DKA) and gangrene poses a significant risk to the patient's morbidity, mortality, and quality of life. When a patient's family refuses a life-saving amputation for DKA with gangrene, the doctor should first ensure the patient's decision-making capacity. If the patient lacks capacity, the doctor should engage in thorough communication with the family, explaining the fatal consequences of untreated gangrene and septicemia, as highlighted in recent guidelines for diabetes care in the hospital 1. This should include a clear discussion of how antibiotics alone cannot resolve established gangrene without source control through surgery. The doctor should explore the family's concerns, values, and cultural beliefs influencing their decision.
Key Considerations
- An ethics consultation should be requested to help navigate this complex situation, and palliative care should be involved early if the family remains firm in their refusal.
- The doctor should document all discussions thoroughly and consider legal intervention if necessary to protect the patient's best interests, though this is typically a last resort.
- Throughout this process, the doctor must continue providing appropriate medical care including insulin therapy for DKA, fluid resuscitation, electrolyte management, and antibiotics, while managing the patient's pain and symptoms, as recommended in the standards of care for diabetes-2024 1.
- The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.
Prioritizing Patient Care
The doctor's primary responsibility is to act in the best interest of the patient, which in this case means prioritizing the patient's medical needs over the family's refusal of the amputation. By considering legal intervention and involving ethics and palliative care, the doctor can ensure that the patient receives the necessary treatment to prevent fatal septicemia and improve their quality of life. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of individualized treatment and prompt intervention in cases of DKA and gangrene 1.
From the Research
Decision-Making in a Life-Threatening Situation
The doctor is faced with a difficult decision when the patient's family refuses a life-saving amputation due to diabetic ketoacidosis (DKA) and gangrene. The following points should be considered:
- The patient's best interests should prevail, as stated in the study by 2, which emphasizes the importance of considering factors such as prognosis, quality of life, and the patient's wishes.
- The family's refusal of the amputation is based on their personal beliefs, but the doctor has a duty to act in the patient's best interests, as discussed in 3, which suggests that the treating surgeon should make a reasoned decision and proceed with the chosen treatment.
- The risk of fatal septicemia if the amputation is not performed is a critical consideration, as highlighted in the study by 4, which discusses the effective treatment of DKA.
Possible Courses of Action
The doctor could consider the following options:
- Respect the family's wish and decision, but this may not be in the patient's best interests, as discussed in 2.
- Seek a court order to override the family's decision, as mentioned in option B, which may be necessary in cases where the patient's life is at risk.
- Report the situation to the authorities, as mentioned in option C, which may be necessary if the doctor believes that the patient's life is at risk and the family's decision is not in the patient's best interests.
- Meet with the ethical committee, as mentioned in option D, to discuss the situation and determine the best course of action, as suggested in 2, which emphasizes the importance of considering the patient's best interests.
Consideration of the Patient's Autonomy
The patient's autonomy and right to make decisions about their own care should be respected, but in this case, the patient is unconscious and unable to make decisions. The doctor must therefore act in the patient's best interests, as discussed in 5, which highlights the importance of respecting the patient's autonomy while also considering the interests of society as a whole.