DELIRIUM and DECISIONS.

A 64-year-old man with known peripheral vascular disease who was recently diagnosed with occlusions in his right and left superficial femoral arteries, was brought to the emergency department for progressive bilateral lower leg pain. Amputation was offered to the patient at that time, but the patient and his family opted to wait and see if he improved. Physical exam was notable for malodorous lower extremities with dry gangrene in multiple phalanges, extensive necrotic ulcerations on both anteromedial shins, without palpable peripheral pulses. Initial labs were significant for leukocytosis and an elevated troponin without accompanying ECG changes. The surgical team again recommended amputation. The patient refused, saying he thought his legs would heal on their own, and he would only want the surgery if there were no other options. On hospital day two, the patient became tachycardic. His leukocytosis worsened, his troponin increased and his mental status deteriorated. Initially, the psychiatry department deemed that he retained decision capacity, and he continued to decline the amputation. However, each day thereafter, the psychiatry department determined the patient to be delirious and without capacity to make medical decisions. The patient's sepsis persisted despite an aggressive antibiotic regimen and his mental status failed to improve. With the patient urgently needing surgery, but unable to consent for the amputation, his adult children assented for the operation on his behalf.