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 actually C. Medical and supportive care only, as the evidence suggests that palliative care can be beneficial in the management of elderly injured patients, focusing on comfort, dignity, and quality of life, especially when the patient has a high risk of mortality and poor outcomes due to their age, comorbidities, and severity of injury 1.

The patient's presentation with vomiting, nausea, abdominal pain, distended and tympanic abdomen, rebound tenderness, fever, and tachycardia suggests a severe condition, but given his age, history of MI and CVA, and lack of decision-making capacity, the focus should be on alleviating suffering and improving his quality of life rather than pursuing aggressive surgical intervention. The evidence from the 2023 WSES guidelines on the management of trauma in elderly and frail patients highlights the importance of palliative care in such cases, where the goal is to provide holistic support and improve the patient's overall well-being during their remaining time 1.

Some key points to consider in this decision include:

• The patient's advanced age and comorbidities, which increase his risk of mortality and poor outcomes from surgical intervention 1.
• The importance of palliative care in managing elderly injured patients, which can help alleviate suffering, improve quality of life, and support the patient's family throughout the process 1.
• The need for a multidisciplinary approach to decision-making, involving palliative care teams and the patient's family, to ensure that the patient's wishes and values are respected 1.
• The potential benefits of early palliative care consultation, which can help reduce suffering, improve outcomes, and reduce non-beneficial and unwanted care 1.

In this case, while the son's request for everything possible to be done to save his father's life is understandable, the evidence suggests that a more appropriate approach would be to focus on medical and supportive care only, prioritizing the patient's comfort, dignity, and quality of life. The wife's refusal of surgical intervention should also be considered, and the decision-making process should be thoroughly documented. Urgent surgical exploration may not be the best option, given the patient's high risk of mortality and poor outcomes, and the potential benefits of palliative care in improving his quality of life.

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.