What should a doctor do when a patient's family refuses a life-saving amputation due to personal beliefs?

Management of a Diabetic Patient with Gangrene When Family Refuses Amputation

In the case of an unconscious diabetic patient with gangrene requiring amputation where the family refuses consent, the doctor should seek a court order to proceed with the life-saving amputation.

Legal and Ethical Framework

When a patient lacks capacity due to being in a diabetic ketoacidosis-induced coma, and requires urgent amputation of a gangrenous foot to prevent fatal septicemia, the following approach is warranted:

Assessment of Capacity and Urgency

• The patient is clearly incapacitated and unable to make medical decisions
• Gangrene represents an immediate life-threatening condition that will lead to septicemia if untreated
• The medical intervention (amputation) is necessary to preserve life

Family Refusal Based on Cultural/Religious Beliefs

While the family's cultural or religious beliefs about bodily integrity after death deserve respect, these considerations cannot override the patient's right to life-saving treatment when:

1. The patient lacks capacity to make decisions
2. There is no advance directive refusing such treatment
3. The treatment is medically necessary to prevent death
4. The family's decision is not in the patient's best medical interests 1

Appropriate Course of Action

1. Continue dialogue with the family to understand their concerns and explain the inevitable fatal outcome without intervention
2. Consult the hospital ethics committee for additional guidance and support
3. Seek urgent legal intervention through the court system 1
4. Document all discussions thoroughly in the medical record

Legal Basis for Court Intervention

The Mental Capacity Act and similar legislation in many jurisdictions establish that:

• Treatment may be provided to incapacitated patients when it is deemed necessary and in their best interests 1
• Doctors have a duty to provide treatment that is medically necessary to preserve life
• Courts can authorize treatment when there is disagreement about what constitutes the patient's best interests 1

In this case, the family's refusal is not based on what would provide the best outcome for the patient in terms of morbidity, mortality, and quality of life, but rather on cultural or religious beliefs about bodily integrity after death.

Avoiding Common Pitfalls

1. Delay in seeking legal intervention: Gangrene can rapidly progress to fatal septicemia; legal consultation should be sought immediately while continuing medical stabilization

2. Inadequate documentation: All discussions with family, medical reasoning, and steps taken should be thoroughly documented

3. Failure to involve appropriate resources: Ethics committee consultation should be initiated early in the process

4. Abandoning the patient: Regardless of the conflict, the medical team must continue to provide all other appropriate care while the amputation decision is being resolved 1

Conclusion

While respecting family beliefs is important, when a patient lacks capacity and faces imminent death without intervention, the physician's primary duty is to preserve life. When family decisions conflict with this duty, legal intervention through the court system is not only justified but ethically required.