Inability to obtain formal informed consent in the face of a standard surgical indication

A thirty-eight-year-old intoxicated man was admitted to the surgical trauma service following a single motor vehicle accident. He had a severe closed head injury, bilateral pulmonary contusions, a fracture-dislocation of the right acetabulum, and an open injury of the right knee joint. The acetabula r fracture pattern was an associated both-column fracture with the femoral head dislocated into a widely displaced posterior-column fracture line. The treating physicians agreed that it would be in the patient's best interest to take him to the operating room for emergent debridement and irrigation of his knee wound. At surgery, the patient also underwent attempted closed reduction of the acetabular fracture and placement of a skeletal traction p in. Radiographs obtained with the patient in traction showed reduction of t he femoral head beneath a displaced superior dome fragment, but there remai ned a 12-mm gap in the posterior column, greater than 3 mm of step incongru ity. and a large articular fragment entrapped in the anterior aspect of the hip joint. The patient remained intubated and sedated for several days. Upon weaning f rom the ventilator, it became evident that his head injury would prevent hi m from being able to give informed consent in the foreseeable future. The p atient's family members refused to become involved with his care or medical decision-making, as he had become completely estranged from them as a resu lt of his chronic alcohol abuse. Further delay in surgical treatment ment f or the acetabular fracture would be associated with greater difficulty in o btaining an anatomic reduction, the potential for additional articular dama ge to the femoral head, and an increased risk of surgical complications, Th e question that arises is whether it is in the patient's best interest for the surgeon to proceed with open reduction and internal fixation of the ace tabular fracture without having had the opportunity to fully inform him of the treatment; options or the risks associated with an extensive surgical e xposure.