What is the most appropriate course of action for obtaining consent for a Coronary Artery Bypass (CAB) operation in an unconscious patient whose relative is unavailable?

Emergency Consent for Unconscious Patient Requiring CAB Surgery

In this life-threatening emergency situation where the patient is unconscious and unable to consent, proceed immediately with the CAB operation without waiting for the relative, as the emergency principle and best interests doctrine authorize treatment to prevent death or serious harm. 1, 2

Legal Framework for Emergency Treatment Without Consent

The Emergency Principle Applies Here

• When a patient lacks capacity and requires urgent life-saving treatment, physicians are legally authorized to proceed based on the patient's best interests without obtaining consent from relatives or the court. 1, 2

• The emergency principle specifically protects practitioners from trespass claims when treatment cannot be delayed without causing additional harm or risk to the patient. 3

• This patient has already failed thrombolytic therapy and PCI, making CAB surgery the definitive life-saving intervention that cannot be postponed. 1

Best Interests Decision-Making

• The treating physician (cardiac surgeon) must make the treatment decision based on the patient's best interests, considering medical factors, previously expressed values, general well-being, and spiritual/religious welfare. 2, 1

• Best interests encompass "welfare in the widest sense, not just medical but social and psychological," and require attempting to understand what the patient's attitude toward treatment would likely be. 1

• The decision must be clearly documented in the medical records, including the grounds for determining lack of capacity, the treatment undertaken, and how it serves the patient's best interests. 1

Why Other Options Are Inappropriate

Option A (Waiting for Relative) - Contraindicated

• Delaying life-saving surgery to wait for a relative would cause additional harm and potentially death, which violates the physician's duty to act in the patient's best interests. 1

• The guideline explicitly states that if delay "would cause additional harm or risk," treatment must not be postponed. 1

Option B (Phone Consent from Relative) - Not Required

• In emergency situations, relatives do not have legal authority to consent or refuse life-saving treatment for incapacitated adults. 1, 2

• Family members should be consulted when considering best interests, but "failure to do so should not compromise care in an emergency." 1

• The relative's input is valuable but not legally necessary when immediate life-saving intervention is required. 1, 2

Option C (Local Guardian) - Impractical and Unnecessary

• Appointing a guardian requires court involvement and takes weeks to complete through the Office of the Public Guardian. 1

• This delay would be fatal in a patient requiring emergency CAB surgery. 1

Option D (Court Order) - Not Required for Emergencies

• Court orders are only necessary for elective procedures in patients lacking capacity who have no legal guardian. 1

• The emergency nature of this situation exempts it from requiring court authorization. 1

Practical Implementation

Immediate Actions Required

• Document the patient's unconscious state and inability to provide consent in the medical record. 1

• Record the failed thrombolytic therapy and PCI, establishing the urgent need for CAB surgery. 1

• Document that the relative is unavailable and that delay would cause harm or death. 1

• Proceed with surgery based on best interests determination by the cardiac surgeon. 1, 2

Post-Operative Responsibilities

• Inform the relative as soon as they become available about the emergency surgery that was performed and the reasons it could not be delayed. 1

• Document all attempts made to contact the relative and the timeline of events. 1

Critical Pitfalls to Avoid

• Do not delay life-saving treatment to obtain consent from relatives in true emergencies - this violates the duty to act in the patient's best interests and can result in preventable death. 1

• Do not assume relatives have legal authority to consent for incapacitated adults - unless they hold a valid health and welfare Lasting Power of Attorney, relatives serve only as consultants in best interests decisions. 1, 2

• Do not seek court orders for emergency interventions - this is only required for elective procedures and would cause fatal delays. 1