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 poor outcomes 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 current guidelines on the management of elderly and frail patients 1.
The patient's clinical presentation of 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 risk of surgery may outweigh the potential benefits. The 2023 WSES guidelines on the management of trauma in elderly and frail patients emphasize the importance of palliative care in such cases, highlighting its role in improving patient comfort, reducing suffering, and enhancing quality of life 1.
Key points to consider in this case include:
- The patient's advanced age and significant comorbidities, which increase the risk of poor outcomes from surgical intervention.
- The lack of autonomy and the need for surrogate decision-making, which is complicated by the disagreement between the patient's wife and son.
- The importance of palliative care in managing elderly and frail patients, as emphasized by current guidelines 1.
- The potential benefits of palliative care, including improved patient comfort, reduced suffering, and enhanced quality of life 1.
In this context, option C: Medical and supportive care only is the most appropriate level of care, as it prioritizes the patient's comfort, dignity, and quality of life while acknowledging the high risk of surgical intervention. This approach is supported by the guidelines and studies cited, which emphasize the importance of palliative care in managing elderly and frail patients 1.
From the Research
Patient Assessment and Care Options
The patient presents with vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, and a fever of 38.5°C, indicating a potential surgical emergency. The patient's history of myocardial infarction (MI) and cerebrovascular accident (CVA) 5 years ago, which has resulted in trouble speaking and a lack of autonomy, adds complexity to the decision-making process.
Level of Care Appropriate for the Patient
Given the patient's condition, the following options are considered:
- Urgent surgical exploration: This option is supported by the study 2, which emphasizes the importance of early surgical consultation and intervention in emergency surgical cases.
- Medical and supportive care only: This option may be considered if the patient's condition is deemed inoperable or if the patient's quality of life would not be improved by surgical intervention.
- Initiation of hospice care: This option may be considered if the patient's condition is terminal and the focus should be on palliative care, as discussed in studies 3, 4, and 5.
- Attempt intervention by local district judge court: This option is not directly related to the patient's medical care and would not be an appropriate response to the patient's immediate medical needs.
Considerations for Decision-Making
The patient's wife has refused operation, while the patient's son demands that everything possible be done to save the patient's life. The decision-making process should involve open communication between the healthcare providers, the patient, and the patient's family, as emphasized in study 2. The patient's lack of autonomy and trouble speaking should also be taken into account, and efforts should be made to understand the patient's wishes and values.
Palliative Care Considerations
Studies 3, 4, and 5 highlight the importance of palliative care in surgical patients with serious illnesses. The patient's symptoms, such as pain, weakness, and dyspnea, should be addressed through palliative care interventions, as discussed in study 6. The patient's psychological and social distress symptoms, such as depression, anxiety, and economic difficulties, should also be considered and addressed through appropriate interventions.