A Family in Conflict, a Large Infarct, and Whether to Start Anticoagulation

Separate the medical questions from the surrogate-authority questions, and do not let a nurse or a single family member settle it at the bedside.

• Confirm decisional capacity: with global aphasia and inconsistent command following, she cannot currently participate in a complex decision. Document that.
• Identify the legally authorized decision-maker under your state's hierarchy. The son's durable power of attorney for healthcare generally governs over a disagreeing sibling, but verify the document's scope and any limitations.
• Establish what she would have wanted, not what the family wants. Ask both children open-ended questions about prior statements, values, and any earlier conversations about dependence, nursing home placement, or feeding tubes. Written advance directives, if any, take priority.
• Note that these are two different decisions: a PEG for a patient with severe dysphagia and a poor neurologic prognosis (where evidence of benefit is weak) and anticoagulation for stroke prevention (which may or may not serve comfort-focused goals). They need not be decided together.
• Convene a structured family meeting with a palliative care consult, use a trained interpreter if language is an issue, and take time - but set a time-limited review if the family cannot agree.

There is no role for anticoagulation in the hyperacute phase, and timing in a large infarct is a genuine risk calculation.

• Anticoagulation is not acute stroke therapy for atrial fibrillation; it is secondary prevention, and starting it immediately in a large infarct raises the risk of hemorrhagic transformation.
• Practical approach: repeat imaging before starting, usually within the first 1–2 weeks. A commonly used framework stratifies by infarct size (for example, roughly 1 day after TIA, 2–3 days after a small infarct, around 6 days after a moderate infarct, and 2 weeks or more after a large infarct with hemorrhagic risk). Recent randomized data support early initiation in many patients, so this is a judgment call to discuss, not a fixed rule.
• Choose a direct oral anticoagulant over warfarin in most nonvalvular atrial fibrillation, including older adults, unless there is a mechanical valve or moderate-to-severe mitral stenosis. Avoid aspirin as a substitute.
• Do not bridge with heparin.
• Falls and HAS-BLED 3 are not, by themselves, contraindications; the absolute stroke risk usually dominates. But if the family chooses a comfort-focused plan, deprescribing anticoagulation can be a legitimate, documented decision rather than an omission.

Use process, not persuasion, to move forward.

• Continue treating the patient with measures that are beneficial under almost any goal set - swallowing safety, positioning, skin care, pain and agitation management, bowel and bladder care, and mobilization as tolerated.
• Hold the PEG and the anticoagulation decision rather than defaulting. Document the disagreement, who holds authority, and the options presented.
• Escalate: palliative care, then the ethics consultation service. The ethics committee can clarify the surrogate hierarchy and the substituted-judgment standard without taking sides.
• Consider a time-limited trial of hand feeding with a speech-language pathologist rather than an immediate PEG; many patients with severe dysphagia do not regain meaningful oral intake, and PEG placement does not improve survival or functional recovery in this population.
• Check your state's dispute-resolution statute; some require ethics committee review or a second opinion before a surrogate's decision is implemented over objection.
• Consider whether the daughter's 'everything' reflects a misunderstanding of what the interventions actually accomplish; explain in concrete terms what a PEG and a recurrent stroke would mean for her mother's day-to-day life.