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- 1. A Dilemma of Blood Transfusion Lindsay Bussard Chris Cummings Jaclyn Nicholson
- 2. The Case • A 28 year old woman, Sarah, spends a day hiking/climbing with her boyfriend, Justin.
- 3. The Case • Sarah falls during the hike and suffers multiple injuries including a large laceration her right thigh. • She is airlifted by search and rescue to a local hospital
- 4. The Case • Justin is able to inform the medical crew that Sarah has ITP. • ITP explains her profuse bleeding.
- 5. The Case • Sarah’s vital signs are unstable at ER • Unconscious • The medical team believes she will need a transfusion
- 6. The Case Sarah’s mother, Janet, informs the team Sarah is Jehovah’s Witness and would not want the transfusion, but Justin pleads for the transfusion to be given.
- 7. Ethical Questions Should the medical team honor Sarah’s supposed religious wishes even if it means her life will be lost? Should the team regard Janet’s thought’s about her daughter’s wishes as absolute?
- 8. Ethical Questions Should Justin, as Sarah’s boyfriend, have a say in her care? Should the team give Sarah what they believe is the best possible treatment?
- 9. Ethical Questions How does the team decide what Sarah would truly want without her input?
- 10. Step 2: Gut Reaction QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. The gut reaction is to save this young woman’s life.
- 11. Step 3: What are the clinically relevant facts? The Bible states in various places that people should not eat blood. Jehovah’s Witnesses interpret this to mean that they are not to take blood into their body in any manner, including transfusion.
- 12. Step 3: What are the clinically relevant facts? Sarah does not have a living will. She is also not carrying a signed card with her stating that she would refuse a blood transfusion in an emergency.
- 13. Step 3: What are the clinically relevant facts? Several court cases have set the precedent that a conscious, competent individual can refuse a blood transfusion, even if doing so will cause their life to be in danger.
- 14. Step 3: What facts do you need to gather? Does Janet or Justin have a signed document stating Sarah’s wishes? Does the medical team know Sarah and have previous knowledge of her stance on blood transfusions? Is Sarah pregnant? In this case she may be forced to receive a transfusion against her wishes.
- 15. Step 4: What are the values at stake for all the relevant parties? Sarah: Life and Autonomy Janet: Eternal Life and Autonomy Justin: Life and Non-maleficence Medical Team: Respect for patient’s rights and Beneficence
- 16. Step 5: What could you do? • Give the transfusion. • Try an alternative treatment. • Do nothing.
- 17. Step 6: What should you do? Give the transfusion to save her life.
- 18. Step 7: Justify Your Choice •We want to respect Sarah’s wishes, but she is unable to tell them to us. •Justin and Janet cannot agree as to what the proper treatment is for Sarah. •As healthcare providers, we decided to err on the side of life.
- 19. Decision to Transfuse •We therefore decided to give Sarah a blood transfusion. •Once she is stable, we will strive to obtain her personal wishes and advocate for them during the rest of her treatment.
- 20. Values to Uphold •Performing the transfusion, we are promoting beneficence and non- maleficence, while seeking to restore Sarah’s autonomy upon recovery. We as providers have a respect for Sarah’s life, but also want to maintain and respect Sarah’s rights and integrity.
- 21. Codes of Ethics Our codes of ethics drive us as providers in the right direction. Sarah is our patient, and as nurse, physician assistant, and doctor, we value our patient first and foremost and act as advocates for her. The best interest of Sarah is to stabilize her such that she can state her wishes so that they can be promoted from there.
- 22. Possible Counterargument Sarah is an adult, and if her mother states she is a Jehovah ’s Witness, those wishes need to be respected. After all, if Sarah’s had ITP for some time, and has yet to receive blood to treat it, is it really that difficult to think that she would not want blood now either?
- 23. Response Sarah has never been put into a life-or-death situation before, and as such, we cannot determine what her wishes are, as they may change given her imminent health status. We as providers have Sarah’s best interest in mind, and her best interest right now is to do everything possible to continue to live.
- 24. Step 8: How could this ethical issue have been prevented? Sarah could have avoided this situation, as anyone can avoid such a situation, via a power of attorney or a living will. These documents would have appointed a sole person as her proxy decision-maker, or described her wishes regarding specific medical treatments in various healthcare situations.
- 25. References • The Bible, New International Reader’s Version • Cases – • www.watchtower.org Official JW Site • Anesthesiology News, October 1989. • Watchtower magazine, June 15, 2004. • Management of the severly anemic patient who refuses transfusion: Lessons learned during the care of a Jehovah’s Witness. Mann et. al., Annals of Internal Medicine. v 117, n12. 15 Dec 1992. • www.cobar.org Information on Advanced Medical Directives Norwood Hosp. v. Munoz 409 Mass. 116; 564 N.E.2d 1017 (1991) In re Estate of Brooks, 32 Ill. 2d 361, 205 N.E.2d 435 (1987)
Editor's Notes
- Sarah is so young with so much life ahead of her. As healthcare providers whose mission is to make every effort to help our patients, the gut reaction to this case is to give Sarah the blood transfusion and likely save her life.
- Jehovah’s Witnesses believe that taking whole blood or its four main parts (red cells, white cells, platelets, and plamsa) is a sin. However; taking smaller fractions of blood such as immunoglobulin or clotting factors may be accepted by certain individuals. The basis for this belief is found in Biblical passages warning against the ingestion of blood. Genesis 9:4 states “But you must not eat meat that still has blood in it.” Leviticus 17:10 says “Suppose someone eats meat that still has blood in it. It does not matter whether he is an Israelite or an outsider. I will turn against him if he eats it. I will cut him off from his people.” Also, Acts 15:29 reads “Don't drink blood.”
- The official Jehovah’s Witnesses website cites a passage from an article written by a physician that reads "Most [Witnesses] readily sign the American Medical Association form relieving physicians and hospitals of liability, and many carry a Medical Alert [card]. A properly signed and dated 'Refusal to Accept Blood Products' form is a contractual agreement and is legally binding.“ However; since Sarah has no such documentation, the law states that all interested parties have a say in Sarah’s treatment. They must agree on a proxy decision maker, and if they cannot agree, then a court proceeding will appoint one. Since this is an emergent situation, they medical team likely will not be able to wait for all interested parties to reach a consensus, and will have to make the final decision.
- Court cases involving Jehovah’s Witnesses have repeatedly stated that individuals have a right to refuse medical treatment, and that it is not considered medically-assisted suicide, even if the refusal is life-threatening. It is much easier legally to force a transfusion on a minor, as well as on someone who is pregnant in some states. But, because Sarah is an adult who is not pregnant, the legal precedent is that she can refuse the transfusion. However; Sarah is unconscious and cannot object to the transfusion, and she also does not have a legal document refusing the transfusion. The only evidence that Sarah would refuse a transfusion comes from her mother, but this is contradicted by her boyfriend, leaving the medical team with no proof that they should legally withhold the transfusion.
- (I think just reading these questions would work for this slide.)
- The central issue for this case is that we do not know what values are most important to Sarah. Is it her current life or her religious beliefs and her eternal life? Janet values Sarah’s eternal life most. She believes that by taking the transfusion, Sarah would be receiving a small amount of extra time in this life but would suffer eternally in the next life. Autonomy and the right to conscientious objection are also important values to Janet. On the other hand, Justin values Sarah’s present life the most. He is acting in a non-maleficent manner by not wanting to cost Sarah her life because of a religious belief she may or may not hold. The medical team must try to weigh all of this and act in a beneficent manner. They must respect Sarah’s wishes if they could be clearly known, but must otherwise seek to provide her the best care possible.
- The medical team may decide that since they have no legal or binding proof that Sarah would not want the transfusion, they should give her the transfusion in an effort to save her life. Alternative strategies include giving fluid to restore volume, giving erythropoietin, iron, and vitamin K to stimulate red cell production, giving oxygen to maximize oxygen delivery, and inducing paralysis or hypothermia to minimize oxygen utilization. Finally, the team may elect to do nothing if they believe no treatment other than transfusion will be helpful and they do not want to risk compromising Sarah’s religious beliefs.
- I’m not sure what we should say on this slide, since they next slide will be justification. Maybe just something like “After weighing each of the possible decisions, the one that makes the most sense with such limited information on Sarah’s wishes is to give her the transfusion.”
- Sarah is an adult, and while she is capable of making her own decisions, she has been put into a situation where she is unable to verbally make her wishes known. Due to the fact that Justin is advocating for a blood transfusion, while Janet is explicitly against it, we as healthcare providers must err on the side of life. After all, who is to say that Sarah hasn’t changed her views since dating Justin?
- Until Sarah is able to state her wishes, even if they include refusal of blood products, we must do everything within our power to save her life, including giving Sarah a blood transfusion. While it may seem to the contrary given Janet and Justin’s conflicting beliefs about Sarah’s religion, we as her providers value and are trying to uphold Sarah’s autonomy, which we hope to restore upon stabilization.
- As the values at stake for Sarah include beneficence, non-maleficence, and respect for life, we cannot simply allowing Sarah to die without truly knowing her wishes in such a situation. Once Sarah is stabilized and awake, we can then reevaluate our care methods based upon her decisions, such that her integrity and autonomy are continually promoted as are her patient rights.
- Per the nursing code of ethics, Sarah is the primary concern. Once her wishes are definitively known, a nurse should will strive to advocate for Sarah and her beliefs, but until then, a nurse must consider her loved ones and account for their needs and wishes. According to the physician assistant code of ethics regarding informed consent, When the person giving consent is a patient’s surrogate, the PA should take reasonable care to assure that the decisions made are consistent with the patient’s best interests and personal preferences, if known. If the PA believes the surrogate’s choices may not reflect the patient’s wishes or best interests, the PA should work to resolve the conflict. This may require the use of additional resources, such as an ethics committee. The physician’s code of ethics states that Informed consent is a basic policy in both ethics and law that physicians must honor, unless the patient is unconscious or otherwise incapable of consenting and harm from failure to treat is imminent.
- It is impossible to determine just how much of a friend Justin is to Sarah, or how much he really knows about Sarah. Janet of all people would know her daughters ultimate wishes as a Jehovah’s Witness, and those wishes should be obeyed. If they are not, Sarah’s autonomy is threatened, as is her beneficence. One can’t help but think, if Sarah receives blood products and then still passes, is it really worth her family believing that she will not have eternal life due to our actions?
- Sarah’s autonomy has been placed in her loved ones hands by Colorado law, and all concerned parties wishes must be taken into consideration. Since Sarah is quickly deteriorating, the providers have no choice but to save her life with a blood transfusion that Justin is advocating for – and in doing so, aim to restore her autonomy such that she can speak for herself. In the end, Sarah had never been or thought she would be in such a healthcare emergency, with her life on the line. WE cannot determine what her wishes in such a situation might be as they may change given her imminent health status. Furthermore, by no means would we strive to give blood to Sarah who is an apparent Jehovah ’s Witness if it weren’t life-threatening not to do so.
- This unfortunately is a common ethical situation, where the stated wishes of someone conflict from two sources, or were never formally put onto paper. As a result, the patient’s wishes get contorted, and ultimately not carried out in a time of need. Had such documentation as a power of attorney or living will been done, Janet could have brought it to the hospital, and any blood product efforts on Sarah would have based upon her personal decisions.