The ethics of surgery in the elderly demented patient with bowel obstruction

Objective: Little has been written in the medical literature concerning the ethics of treatment of the elderly demented patient with bowel obstruction. It is one example of the issues with which we are becoming increasingly involved. We conducted a survey of our colleagues' opinions to determine current practice. Design: A postal questionnaire study (62% response rate). Questions were posed that related to a case scenario of an elderly demented patient presenting with a presumed sigmoid volvulus. Setting: The northern region of England. Participants: Thirty seven surgical members of the Association of Coloproctology of Great Britain and Ireland, Northern Chapter. Results: Sixty five per cent of respondents felt that surgery would be inappropriate, and 26% that any intervention at all upon the subject in the case scenario would be inappropriate. More would operate, however, at the request of relatives. An advance directive not to treat would be respected by 70% despite a relative's wishes. Conclusions: Overall there was a wide variation in the approach of the surgeons to a demented patient with bowel obstruction. In an era of clinical governance, and an increased awareness of the ethics of consent, this study presents one example of the difficult decisions with which we are increasingly faced, The greater use of advance directives may provide one possible solution.