What level of care is appropriate for an 84-year-old patient with a history of two myocardial infarctions (MIs) and a cerebrovascular accident (CVA) five years ago, presenting with symptoms of acute abdomen, including vomiting, nausea, abdominal pain, distension, tympanic abdomen, rebound tenderness, fever, tachypnea, and tachycardia, who requires surgical intervention but lacks autonomy due to post-CVA aphasia and has conflicting opinions from family members regarding treatment?

From the Guidelines

The most appropriate level of care for this 84-year-old patient is option C: Medical and supportive care only, as the patient's advanced age, significant comorbidities (history of MI and CVA), and current clinical presentation suggest a high risk of mortality and morbidity from surgical intervention 1. Given the patient's lack of autonomy and the disagreement between his wife and son regarding his care, a palliative approach focusing on comfort, dignity, and quality of life is most aligned with his best interests.

The patient's clinical presentation, including vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, fever, and tachycardia, suggests a severe abdominal condition that may require surgical intervention. However, considering his age and comorbidities, the risks associated with surgery may outweigh the potential benefits. The study by Aziz et al. 1 suggests that early palliative care consultations can improve outcomes, such as length of hospital stay, and reduce non-beneficial and unwanted care in geriatric trauma patients.

In this scenario, the patient's wife, as his legal surrogate, has refused the operation, while his son wants aggressive intervention. However, the patient's best interests should be the primary consideration. The study by Baimas-George et al. 1 found that involving palliative care systems can decrease suffering, improve outcomes, and reduce non-beneficial and unwanted care. Therefore, providing medical and supportive care only, with a focus on palliation, is the most appropriate approach.

This approach is supported by the study by Davies et al. 1, which found that early intervention of palliative care can be successful in high-risk patients, even if mortality rates remain high. Additionally, the study by Schuijt et al. 1 suggests that a patient-tailored treatment associated with a decision-making multidisciplinary team can be helpful in these situations.

In terms of specific care, the medical team should provide stabilizing care, including IV fluids, antibiotics if infection is suspected, nasogastric decompression, and pain management, while focusing on the patient's comfort and quality of life. This approach respects both the ethical principle of beneficence and the legal requirements for proper consent in a patient lacking capacity when surrogates disagree.

Key considerations in this case include:

• The patient's advanced age and significant comorbidities, which increase his risk of mortality and morbidity from surgical intervention
• The disagreement between his wife and son regarding his care, which highlights the need for a palliative approach that prioritizes his best interests
• The importance of early palliative care consultations in improving outcomes and reducing non-beneficial and unwanted care in geriatric trauma patients
• The need for a patient-tailored treatment associated with a decision-making multidisciplinary team to ensure that the patient's care is aligned with his best interests.

From the Research

Patient's Condition and Needs

• 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 temperature of 38.5°C.
• The patient has trouble speaking and does not have the power of autonomy, requiring a surrogate decision maker.
• The patient's son demands that everything possible be done to save his father's life, while the patient's wife refuses operation.

Appropriate Level of Care

• Considering the patient's critical condition, early surgical consultation and intervention can be lifesaving 2.
• The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all healthcare providers, the patient, and his or her family.
• Palliative care has the potential to improve care for patients and families undergoing high-risk surgery, and its integration into standard surgical management can benefit seriously ill or injured surgical patients and their loved ones 3, 4, 5.
• However, the patient's wife has refused operation, and the patient's son demands everything possible be done to save his father's life, creating a conflict in decision-making.

Possible Courses of Action

• Urgent surgical exploration (Option D) may be necessary to address the patient's critical condition, considering the patient's symptoms and history.
• Medical and supportive care only (Option C) may not be sufficient to address the patient's needs, given the severity of his condition.
• Initiation of hospice care (Option B) may be considered if the patient's condition is deemed terminal, but this would require a thorough discussion with the patient's family and healthcare providers.
• Attempting intervention by a local district judge court (Option A) may be necessary to resolve the conflict in decision-making between the patient's wife and son.