What is the most appropriate course of action for obtaining consent for a Coronary Artery Bypass (CAB) operation in an unconscious female patient with a recent history of unsuccessful thrombolytic therapy and Percutaneous Coronary Intervention (PCI), whose relative is unavailable?

Emergency CABG Without Consent: Proceed Immediately Under Emergency Exception

In this life-threatening emergency situation where the patient is unconscious and requires urgent CABG after failed revascularization, proceed with surgery immediately without waiting for consent under the emergency exception doctrine—delaying treatment to obtain consent would significantly increase mortality risk. 1

Legal Framework for Emergency Treatment

The emergency exception to informed consent applies when:

• The patient lacks capacity to consent (unconscious state) 1
• Treatment is necessary to preserve life or prevent serious harm 1
• Delay in obtaining consent would significantly worsen outcomes 1

In this scenario, all three criteria are met. The patient requires emergency CABG after unsuccessful thrombolytic therapy and PCI, representing a life-threatening situation where ongoing ischemia threatens myocardial viability and survival.

Why Other Options Are Inappropriate

Option A (Wait for relative): Unacceptable

• Waiting for the relative to return would delay life-saving surgery and dramatically increase mortality risk 2
• The ACC/AHA/SCAI guidelines emphasize that emergency transfer for coronary bypass surgery is indicated for failed or unstable PCI results with ongoing ischemia 2
• Total ischemic time directly correlates with adverse outcomes in emergency CABG after failed PCI 2

Option B (Phone consent): Legally questionable and unnecessary

• Phone consent from relatives has questionable legal validity and creates documentation challenges 1
• More importantly, it is unnecessary when the emergency exception applies 1
• The guidelines state that "transferring physicians obtain consent for surgery from patients or appropriate surrogates" in planned transfer situations, not true emergencies 2

Option C (Local guardian): Impractical and delays care

• Appointing a local guardian requires legal proceedings that would cause unacceptable delays 1
• This option fundamentally misunderstands the urgency of the clinical situation

Option D (Court order): Inappropriate for emergencies

• Court orders are reserved for non-emergency situations where there is disagreement about treatment or ethical complexity 1
• Seeking a court order in a life-threatening emergency would constitute medical negligence through delay

Clinical Context Supporting Emergency Action

The ACC/AHA/SCAI guidelines specifically identify this patient's scenario as requiring emergency transfer for coronary bypass surgery: 2

• Failed or unstable PCI result with ongoing ischemia is an explicit indication for emergency CABG 2
• These patients should receive IABP support during transfer, emphasizing the critical nature of the situation 2

The guidelines distinguish between situations requiring informed consent (elective procedures) versus emergency situations. The statement that "consent for PCI obtained while the patient is on the table is not informed consent and is unacceptable in non-emergency situations" explicitly acknowledges that emergency situations have different consent requirements 2

Documentation Requirements

While proceeding without consent, document: 1

• The emergency nature of the situation (unconscious patient, failed PCI, ongoing ischemia)
• The life-threatening risk of delay
• The medical necessity of immediate CABG
• Attempts to contact family members (if time permits)
• The clinical judgment that waiting would significantly worsen outcomes

Important Caveat

This recommendation applies specifically to true emergencies where treatment is necessary to preserve life and delay would cause significant harm. 1 If the patient were stable and the surgery could be safely delayed, then obtaining proper consent from surrogates would be required. 2 However, the clinical scenario described—unconscious patient requiring CABG after unsuccessful thrombolytic therapy and PCI—represents a life-threatening emergency where the emergency exception clearly applies.