Thursday, September 22, 2011
Head injury
A 51 year old man comes to the hospital with a severe head injury from a motorcycle accident. He was unconscious upon admittance and had a softball size piece of his scull removed and frozen to relieve pressure on his brain from swelling. The doctor who removed his scull noted significant brain damage, but what this means cannot be determined until he begins rehab. He has regained consciousness after a few days but is not competent. The man needs a PEG for rehab. He has left no advance directive and his only known family member, his mother, refuses to allow the PEG. However, the mother has never visited the man, claiming that she does not have transportation to the hospital. What should the care team do?
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In this situation it would be the most prudent to place the PEG tube despite the voiced objection of the mother. Despite the patient being “conscious” he has still been determined to be incompetent to make medical decisions. This measure will allow for the patient to obtain and then maintain the greatest amount of comfort until a more suitable decision-making modality is used. If the mother still maintains that she cannot physically get to the hospital, then the first step is to get the mother to the hospital using modern technology (i.e. webcam, Skype). Also there needs to be a search for another logical health-care proxy. Also by putting in the PEG and allowing this patient to go to rehab, there is a good chance that the patient could be returned to competency, therefore overriding anything the mother would have to say.
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