From the Guidelines
The appropriate level of care for this 84-year-old patient is option D: Urgent surgical exploration. This patient presents with signs of an acute surgical abdomen (vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, fever, tachycardia) likely requiring urgent surgical intervention, as suggested by the updated guidelines of the World Society of Emergency Surgery 1. The patient's condition is critical, and delaying surgery could lead to severe consequences, including death.
Given the patient's history of myocardial infarction and cerebral vascular accident, it is essential to consider the potential risks and benefits of surgery. However, the patient's current condition suggests that urgent surgical exploration is necessary to prevent further complications. The use of a multidisciplinary team, including a general surgeon, vascular surgeon, interventional radiologist, and intensivist, can help optimize the patient's care and improve outcomes, as recommended by the World Society of Emergency Surgery 1.
While the patient's wife refuses surgery, and the son demands that everything possible be done to save his father's life, the patient's best interests should be the primary consideration. In this case, urgent surgical exploration is likely the best course of action to prevent further harm and improve the patient's chances of survival. The court can evaluate the patient's best interests and determine the appropriate course of action, but delaying surgery could have severe consequences.
The patient should receive appropriate medical stabilization, including IV fluids, antibiotics if infection is suspected, nasogastric decompression, and pain management, as recommended by the World Society of Emergency Surgery 1. The patient's rights and dignity should be respected, and the medical team should make every effort to learn about and treat the patient as a unique individual, incorporating all that is known about the patient's values into treatment decisions, as suggested by the American Thoracic Society/American Geriatrics Society policy statement 1.
Key considerations in this case include:
- The patient's critical condition and need for urgent surgical intervention
- The potential risks and benefits of surgery, given the patient's medical history
- The importance of respecting the patient's rights and dignity
- The need for a multidisciplinary team to optimize the patient's care and improve outcomes.
From the Research
Patient Assessment
- The patient is 84 years old with a history of 2 MI and CVA 5 years ago, presenting with vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, and a high temperature of 38.5.
- The patient's vital signs include RR 20, HR 101, indicating a potential infection or acute abdominal condition.
- The patient has trouble speaking and does not have the power of autonomy, which raises concerns about decision-making capacity.
Medical Decision-Making
- The patient's wife has refused operation, while the son demands that everything possible be done to save the patient's life, creating a conflict in decision-making.
- In such cases, the primary goal is to provide appropriate medical care while respecting the patient's autonomy and the family's wishes.
- However, the patient's condition suggests a potential surgical emergency, such as an acute abdominal condition or severe infection, which requires prompt attention 2, 3.
Level of Care
- Given the patient's critical condition and potential need for surgical intervention, urgent surgical exploration may be necessary to prevent further complications or death 2, 3.
- The use of broad-spectrum antibiotics and aggressive fluid resuscitation may also be indicated to manage potential infections and prevent sepsis 4, 5.
- The management of the critically ill patient in the emergency department requires careful consideration of safety issues and the potential need for intensive care unit (ICU) admission 6.
Appropriate Course of Action
- Considering the patient's condition and the potential need for surgical intervention, option D (Urgent surgical exploration) may be the most appropriate course of action.
- However, this decision should be made in consultation with the patient's family and healthcare team, taking into account the patient's autonomy and best interests.