A 79-year-old man is brought to the emergency department due to a 2-day history of fever and confusion. His wife reports he has a history of diabetes mellitus; he is frequently noncompliant with his insulin regimen, and his home blood glucose has been 400 mg/dL for the last few days. Temperature is 39.5 C (103.1 F), blood pressure is 90/60 mm Hg, pulse is 118/min, and respirations are 20/min. The patient is confused and ill appearing. He is oriented to person but not place or time. The perineum is erythematous, warm, and tender to palpation; areas of skin sloughing associated with malodorous discharge are present. CT scan of the abdomen and pelvis reveals necrotizing infection of the perineum. Intravenous fluids, insulin, and antibiotics are administered, and the surgical team is consulted. The emergency department physician has a discussion with the patient's wife about the diagnosis and treatment plan. The patient repeatedly says, "I just want to go home. Do not cut me." Which of the following is the best next step in management of this patient?

Question

A 79-year-old man is brought to the emergency department due to a 2-day history of fever and confusion.  His wife reports he has a history of diabetes mellitus; he is frequently noncompliant with his insulin regimen, and his home blood glucose has been >400 mg/dL for the last few days.  Temperature is 39.5 C (103.1 F), blood pressure is 90/60 mm Hg, pulse is 118/min, and respirations are 20/min.  The patient is confused and ill appearing.  He is oriented to person but not place or time.  The perineum is erythematous, warm, and tender to palpation; areas of skin sloughing associated with malodorous discharge are present.  CT scan of the abdomen and pelvis reveals necrotizing infection of the perineum.  Intravenous fluids, insulin, and antibiotics are administered, and the surgical team is consulted.  The emergency department physician has a discussion with the patient's wife about the diagnosis and treatment plan.  The patient repeatedly says, "I just want to go home.  Do not cut me."  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1e0_acb0_8f63_394bb8232987_MD0005_00 This patient has an acute, gangrenous infection of the perineum (ie, Fournier gangrene) complicated by sepsis (ie, fever, tachycardia, confusion). Fournier gangrene is a life-threatening form of necrotizing fasciitis and requires urgent surgical exploration and debridement. Informed consent must be obtained prior to any surgical procedure and requires that the patient has the capacity for decision-making. The 4 requisite criteria for decisional capacity include the ability to: Communicate the patient's choice of management options Understand the medical condition and proposed treatment Appreciate the consequences of treatment options (including no treatment) Provide a rationale for the decision Although this patient indicated he does not want surgery, he is confused and disoriented. His ability to understand the condition or consequences of treatment refusal is impaired. In such cases, decision-making falls to a designated proxy decision maker (eg, durable power of attorney) or, in the absence of a designated proxy, the next of kin (ie, default surrogate). The order of next of kin is determined by the proximity of relationship; priority goes to the patient's spouse, adult children, parents, and adult siblings, sequentially. Therefore, this patient's wife should be asked to provide consent or refusal for surgery based on what the patient would have wanted (ie, substituted judgment) and the patient's best interest. order of next of kin (Choices A, D, and E) Fournier gangrene is a life-threatening emergency. In this patient with hypotension, surgery is necessary immediately and should not be delayed while awaiting a court review or improvement in the patient's mental status. (Choice B) If the patient was confirmed to have decision-making capacity and refused surgical intervention, he could be discharged without surgery. However, this patient does not currently possess decision-making capacity, so his wife should be asked to provide consent for him as a surrogate decision maker. Educational objective: Informed consent is required prior to any surgical procedure. If a patient does not have decision-making capacity (eg, due to acute delirium), consent falls to a designated proxy decision maker or the next of kin.

A 79-Year-Old Man Is Brought to the Emergency Department Due