A 72-year-old woman is brought to the emergency department from an assisted living facilit… — USMLE Step 2 CK

A 72-year-old woman is brought to the emergency department from an assisted living facility due to a sudden onset of severe abdominal pain out of proportion to physical findings, accompanied by bloody diarrhea. An urgent CT angiogram of the abdomen confirms acute mesenteric ischemia. Emergency bowel resection is indicated to prevent death. The patient has a 40-year history of treatment-resistant schizophrenia. During the evaluation, she is actively hallucinating and states, "The government put snakes in my belly. If you cut me open, they will escape and eat everyone." She adamantly refuses the surgery. Her vital signs are temperature 37.8°C (100.0°F), blood pressure 90/60 mmHg, pulse 115/min, and respirations 22/min. The medical record includes a valid advance directive executed five years ago during a period of psychiatric stability. This document appoints her eldest daughter as her sole healthcare proxy. The daughter is contacted by phone, understands the grave prognosis, but declines the surgery, stating, "When she was lucid, my mother explicitly told me she never wanted major surgery or life support at this stage of her life." The patient's younger son arrives at the emergency department shortly after. He is distraught and demands that the surgical team operate immediately, stating, "I am her son too! You have to save her, do the surgery now!" Which of the following is the most appropriate next step in management?

Withhold the surgical intervention and initiate palliative care measures as directed by the daughter.Cevap
B
Proceed with the emergency bowel resection based on the explicit consent provided by the son.
C
Initiate conservative management with intravenous antibiotics and observe until the family reaches a unanimous decision.
D
Postpone the surgical decision to determine if this is a brief psychotic disorder that will remit spontaneously.
E
Contact local law enforcement to arrange for an emergency psychiatric hold to mandate the surgery.

Cevap

Withhold the surgical intervention and initiate palliative care measures as directed by the daughter.

This patient requires emergent surgery but lacks decision-making capacity due to her active psychotic delusions, which prevent her from understanding the risks and benefits of the procedure. When a patient lacks capacity, medical decisions are deferred to a surrogate decision-maker. This patient has a valid advance directive appointing her daughter as her healthcare proxy. The authority of a legally appointed healthcare proxy supersedes that of other family members, including the son. Because the daughter is making a decision that is consistent with the patient's previously expressed wishes during a lucid interval, the physician is ethically and legally bound to respect this decision, withhold surgery, and provide palliative care.

Adım Adım Çözüm

Evaluate the patient's decision-making capacity.

The patient lacks capacity because her active delusions prevent her from understanding the clinical reality of her condition.

A patient must have capacity to refuse life-saving medical treatment.

Identify the appropriate surrogate decision-maker.

The daughter is the legally appointed healthcare proxy from an advance directive executed when the patient was stable.

A designated healthcare proxy has legal authority that supersedes other family members.

Determine the appropriate clinical action based on the surrogate's decision.

The proxy refuses surgery based on the patient's known prior wishes.

The medical team must honor the patient's autonomy as exercised through her valid surrogate, despite the son's objections.

Anahtar Kavram

In patients lacking decision-making capacity, a legally appointed healthcare proxy has absolute authority over other family members, and their decisions—when based on the patient's previously expressed wishes—must be respected even if they result in the patient's death.

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Cevap

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