Ethics Quandary

[Rendar5]

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I've got an interesting ethics case and just wondered what people's take on it was. It's a true story, although I know about the details only 2nd hand:

23 year old drunk driver comes in very bad shape from an MVA. Unconscious, crit is horribly low, and doesn't respond to initial treatments. You get in touch with his mother who says he's a Jehovah's witness and even though you tell her without blood he's in serious trouble, she insists that you do not give him any blood products at all. Question here is, what should be done at this point with this limited information?


Ultimately, I'm gonna put the rest of the real story in white text so as to avoid biasing everyone:
The trauma team don't give him blood products. He's transferred to a larger hospital's ICU. The pt's sister then is told what's going on, I forget how, but she rushes over because he is not a Jehovah's Witness and neither is she. They don't suscribe to their mother's religious practices. She can't prove this, he doesn't get blood products. At this point, even if she could prove it, his condition is so destablized that he suffers brain damage and then dies the next day. I will vouch that she was in fact correct as to her brother's religious beliefs

EDIT: this took place in Louisiana, not at one of my hospitals

 

[GeneralVeers]

In this case you have to listen to the mother. In most states the closest relative makes the decisions in cases where the patient has no advanced directive.

Usually the order is Spouse -------> Children ---------> Parents --------Siblings.


In this case you have to assume that the mother is representing his wishes to her, and respect them.

 

[gudog]

I find it hard to believe that a phone number for a mother was found, she was called, and all this drama occurred before several units of O negative blood were already running.

But, if it did happen this way, I think the treating physicians were obligated to defer to the mother's decision here.

 

[SoCuteMD]

In this case you have to listen to the mother. In most states the closest relative makes the decisions in cases where the patient has no advanced directive.

Usually the order is Spouse -------> Children ---------> Parents --------Siblings.


In this case you have to assume that the mother is representing his wishes to her, and respect them.

This is not necessarily the way things work. If a patient have no health care proxy, then you can get a court ordered appointee (this can actually happen in minutes - I've seen it done). In the case of conflict between reported beliefs/desires for care - especially in those where life/death hinges on the decision - there often is a court-appointed decision maker and the decision does NOT necessarily fall to the next of kin. I would argue that in the case of this conflict, you have not only the right as a physician to seek expert opinion regarding the matter, but the obligation to do so. Certainly if the patient were a minor, the mother's argument would hold more weight. However, even then I've seen the attending get on the phone to hospital counsel so that they can get in touch with a judge for a court order.

In addition, I was under the impression that the blood products refusal card was a crucial part of this process. This patient doesn't seem to have one, which may or may not be because he doesn't have one.

This case is not nearly as simple as it's being made out to be. At the very least, hospital counsel needs to be consulted and likely it will end up in front of a judge (by telephone).

One article: http://www.watchtower.org/e/hb/article_06.htm
Mentions that the forms associated with a Jehovah's Witness refusing blood exempt the physician from malpractice suits arising from the issue. However, as the treating physician in this case you don't have those forms. All you have is the word of the mother that the patient is a Jehovah's witness. You have nothing with a signature (or his proxy's signature) to protect you shoudl things go down the drain.

This article looked interesting, but I can't pull it up right now:http://linkinghub.elsevier.com/retrieve/pii/S0039606008000895

 

[Tiger26]

The funny thing is that even before I read further, I was thinking what would happen if he didn't get blood because someone falsely told the team he was a Jehovah's Witness.

A little jaded here, but say you just got into an argument/fight with someone in your family (we'll call it a very big argument), who then sped away, ran into a lightpost, and had some massive bleed. 30 min later you get a call asking about blood products from the ED and, looking to seek revenge, you go "oh, yeah, sure he's definitely a Jehovah's Witness--he never should get blood under any circumstances"

Now, granted the typical patient population probably could never put that type of story together, especially on the spot, but it's a possible scenario . . .

 

[deleted65604]

Short of the patient telling you with his own mouth that he doesn't want blood, give him blood.

If he had a signed note in his possession that specifically said "DOn't give me blood." I would consider not giving him blood, but would probably do it anyway.

You have no idea if he actually believes or not that he will go to hell if he gets blood products.

Uber-religious mothers are very biased and can't be trusted to give you accurate information regarding their adult children's wishes. I know, I have one.

 

[Flopotomist]

If he was unstable, this should be an academic discussion only as blood should have been hanging before a phone call to the mother was even made.

 

[Rendar5]

I find it hard to believe that a phone number for a mother was found, she was called, and all this drama occurred before several units of O negative blood were already running.

Yeah, I'm not quite sure of what the details were in terms of when the mom got into the case and what was done before she got there.

 

[Stitch]

Certainly if the patient were a minor, the mother's argument would hold more weight. However, even then I've seen the attending get on the phone to hospital counsel so that they can get in touch with a judge for a court order.

actually as a minor her wishes count for less, and the younger the kid, the less likely we are to abide by them. I've had to call for a court order (not for trauma, because I agree the blood ought to be hanging before you bother calling family members) on more than one occasion. To tell the truth most parents are relieved. They want their kid to live, they just don't want to bear the burden of making that decision to give a blood product.

I'm curious: I thought that as long as the patient didn't consent to getting blood, a JW wouldn't be ostracized from the community. In other words, the sin is knowingly accepting or so I thought. The JWs I've spoken with about this subject understood that in the ER we err on the side of life, and often have to give blood emergently to a patient who may not be able to voice his beliefs.

But it goes to show why even young health people need to have advance directives.

 

[TexasTriathlete]

I am pretty sure the actual sin is "eating" the blood, which is why the whole idea of not accepting transfusions is ridiculous. Or maybe they changed it.

 

[Interpolfanclub]

You err on the side of treatment. You have a very sick patient and apparently a phone conversation with someone who claims to be the mother saying don't give blood products. I agree, short of the patient telling me not to give them anything, they get the blood. We've all seen the myriad of interpersonal relationships patients have and I definitely am not trusting a phone convo over a sick patient. Too chaotic of a situation, too much medical risk to do anything but give the patient what they need-blood.

 

[TexasTriathlete]

Just out of curiosity, how does life insurance handle something like this?

You've got a patient that can probably be saved with transfusions, but they are refused on religious grounds, and the patient dies. Does the life insurance pay up, or can they tell the family to go f themselves?

 

[tkim]

 

[GeneralVeers]

Yet another religious cult with crazy ideas that make no sense logically.

 

[GeneralVeers]

Just out of curiosity, how does life insurance handle something like this?

You've got a patient that can probably be saved with transfusions, but they are refused on religious grounds, and the patient dies. Does the life insurance pay up, or can they tell the family to go f themselves?

The life insurance would have to pay.

I had a 27-year old Hispanic lady back at MLK who we newly diagnosed with AML. She came in bleeding from the gums and had a hemoglobin of 7. Needless to say she was a JW and died a few days later, as she essentially had no red cells or platelets left in her body.

 

[TexasTriathlete]

On one hand, I don't think people should get medical treatments that they don't want. On the other hand, I wonder if maybe we should treat people like this as though they are ******ed, and incapable of making an informed decision.

I saw this nonsense at the trauma center where I worked quite a few times. It always put everyone in a ****ty mood when forced to not treat the patient for no good reason.

 

[dchristismi]

Add me to the list of those who are surprised our patient didn't already have units hanging. (And on a Level 1 infuser, the first 2 L of crystalloid would be looong gone. And a couple of units would already be in, too.)

And panscanned, and probably already to the OR or ICU...

Besides, the people who make these phone calls don't generally say anything other than "your loved one was taken to County General, and you should come as quickly as possible."

 

[Stitch]

On one hand, I don't think people should get medical treatments that they don't want. On the other hand, I wonder if maybe we should treat people like this as though they are ******ed, and incapable of making an informed decision.

I saw this nonsense at the trauma center where I worked quite a few times. It always put everyone in a ****ty mood when forced to not treat the patient for no good reason.

In an alert, sane adult? I can't speak for others, but if that's a patient's choice and they understand they may die without intervention, why get all worked up? I don't understand it, and I think the JW aversion to blood products is dumb, but it's not my choice. Hopefully they have discussed such choices with their families.

If it's a kid, however, then I get worked up and involved.