From the Guidelines
The appropriate level of care for this 84-year-old patient is D. Urgent surgical exploration. The patient presents with classic signs of an acute surgical abdomen (vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, fever, tachycardia), which likely represents a life-threatening condition such as bowel obstruction, perforation, or ischemia requiring immediate surgical intervention. Despite the patient's advanced age and comorbidities (history of two myocardial infarctions and a cerebrovascular accident), the acute presentation necessitates urgent intervention to prevent death. Since the patient lacks decision-making capacity due to his stroke-related speech difficulties and does not have power of autonomy, the next of kin would typically make decisions. However, there is conflict between the wife (who refuses surgery) and the son (who wants all possible interventions). In such emergency situations where delay would likely result in death and there is disagreement among family members, the physician's duty is to proceed with life-saving treatment while the family conflict is being resolved, as suggested by the American Thoracic Society/American Geriatrics Society policy statement 1. The patient's symptoms strongly suggest peritonitis, which carries high mortality without surgical intervention. Neither hospice care nor medical supportive care alone would address the acute surgical emergency, and waiting for court intervention would likely result in preventable death given the urgency of the situation. According to the World Society of Emergency Surgery guidelines, treatment of acute mesenteric ischemia is optimal in a dedicated center using a focused care bundle and a multidisciplinary team 1. Additionally, the guidelines recommend that patients with suspected acute mesenteric ischemia should undergo fluid resuscitation, correction of electrolyte abnormalities, and nasogastric decompression immediately 1. In this case, urgent surgical exploration is the most appropriate course of action to prevent mortality and improve the patient's quality of life. Key aspects of care include:
- Removal of non-viable ischemic bowel
- Preservation of intestine with revascularization
- Intensive care treatment to prevent progression to multiorgan failure
- Surveillance imaging and long-term anticoagulation for patients undergoing revascularization 1. Overall, the goal is to keep the time to reperfusion as short as possible and to provide multidisciplinary care to optimize outcomes.
From the Research
Patient Assessment
- The patient is 84 years old, presenting with vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, and a fever of 38.5°C.
- The patient has a history of two myocardial infarctions (MI) and a cerebrovascular accident (CVA) 5 years ago, which has resulted in trouble speaking and a lack of autonomy.
- The patient's condition requires immediate attention, and the need for an operation has been identified.
Level of Care
- Given the patient's critical condition and the need for urgent surgical intervention, the most appropriate level of care would be D. Urgent surgical exploration 2, 3.
- The patient's symptoms, such as abdominal pain, distended abdomen, and rebound tenderness, suggest a severe surgical emergency that requires prompt attention.
- The studies suggest that early surgical consultation and intervention can be lifesaving in such cases 2, 3.
- Additionally, aggressive fluid resuscitation and broad-spectrum antibiotics may be necessary to manage the patient's condition 4, 5.
Family Dynamics
- The patient's wife has refused the operation, while the son demands that everything possible be done to save the patient's life.
- In such cases, it is essential to consider the patient's autonomy and the family's wishes, but the primary concern should be the patient's well-being and the need for urgent medical attention.
- The decision to proceed with surgery should be made in consultation with the healthcare team and the family, taking into account the patient's best interests and the potential benefits and risks of the operation.