Mock Interview question

[bshark]

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

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[MedPR]

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

You do the transfusion. As far as I know, emergent circumstance trumps her religious belief.

 

[typicalindian]

I'd ask Sdn

 

[phikapdoctor]

Sleep with the hot nurse.


Sent from my iPhone using SDN Mobile app please excuse punctuation and spelling

 

[pre med 2014]

I'd ask Sdn

Find the nearest computer in the ER and ask SDN pre-meds asap

 

[pre med 2014]

Sleep with the hot nurse.


Sent from my iPhone using SDN Mobile app please excuse punctuation and spelling

Nowhere in that statement did it say the nurse was hot

 

[mimelim]

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

This isn't a hard question or even remotely controversial. There is a right and there is a wrong answer. If you can't get this right, there is something wrong.

 

[tvelocity514]

If it is the patient's signature saying he doesn't want a blood transfusion because he is a JW, you don't give a transfusion.


In a similar case in Canada some years ago an emergency physician treated and transfused a JW patient following a motor vehicle accident. She was unconscious at the time, however she had a card in her wallet which indicated that she was a JW and did not want blood products under any circumstances. She survived and went on to successfully sue the E.R. physician.


Your choices are limited:

1. Have the patient/family sign a release stating that he/they have been informed of the risks of not transfusing and that they accept these risks and absolve you and your hospital of legal liability. (But this can't happen as she is in a coma and there isn't a hypothetical family)
2. Transfuse the patient and expect to be sued.

 

[basedbear]

You do the transfusion. As far as I know, emergent circumstance trumps her religious belief.

wat

 

[sector9]

You do the transfusion. As far as I know, emergent circumstance trumps her religious belief.

Pretty sure patients still have their autonomy, even in emergent circumstances

 

[Ismet]

You do the transfusion. As far as I know, emergent circumstance trumps her religious belief.

Um....no.

EDIT: I just noticed the new emoticons. This is necessary:

 

[MedPR]

wat

Pretty sure patients still have their autonomy, even in emergent circumstances

Pretty sure that medpr guy was being sarcastic.

Sent from my SGH-T999 using SDN Mobile

 

[Owlie]

Um....no.

EDIT: I just noticed the new emoticons. This is necessary:

Indeed it is



HOO! HOO!

I would see if there was a way to save the patient without actually needing a transfusion. I'd also contact the parents if possible to get their consent for a transfusion. If not, oh well. They decided they didn't want one.

 

[darkjedi]

nice

 

[TheShaker]

I'm sorry if I'm sounding stupid here, but I'd like an explanation on the answer to not give her the transfusion.

Is the card legally binding? I feel like there might be even worse legal ramifications if the physician did not do it (assuming there is no legal meaning in the JW card). I would say that it's a naive 18 year old who just made a recent decision on something that she might not even stick with. It would be my job as a physician to keep her alive and a recent decision made by her shouldn't cost her her life. If she wakes up and feels like she was wronged, then fine, she'll eventually realize that I'm the monster, not her, but at least she's alive. I would be fine with being the bad guy if I didn't let someone die over some decision that was made a few weeks ago.

This is assuming that there will be no legal problems afterwards.

 

[darkjedi]

I'm sorry if I'm sounding stupid here, but I'd like an explanation on the answer to not give her the transfusion.

Is the card legally binding? I feel like there might be even worse legal ramifications if the physician did not do it (assuming there is no legal meaning in the JW card). I would say that it's a naive 18 year old who just made a recent decision on something that she might not even stick with. It would be my job as a physician to keep her alive and a recent decision made by her shouldn't cost her her life. If she wakes up and feels like she was wronged, then fine, she'll eventually realize that I'm the monster, not her, but at least she's alive. I would be fine with being the bad guy if I didn't let someone die over some decision that was made a few weeks ago.

This is assuming that there will be no legal problems afterwards.

Legally speaking, I believe there is very legal precedence in this specific situation, at least in the US. Generally speaking, patients have the right to refuse medical treatment.

There is however a very strong legal precedent in regards to minors who's parents forbid their children to receive blood transfusions. In a case of a medical emergency, the state can take temporary custody of the child and the blood transfusion can be given immediately with little worry for legal ramifications.

 

[sunflower18]

Legally speaking, I believe there is very legal precedence in this specific situation, at least in the US. Generally speaking, patients have the right to refuse medical treatment.

There is however a very strong legal precedent in regards to minors who's parents forbid their children to receive blood transfusions. In a case of a medical emergency, the state can take temporary custody of the child and the blood transfusion can be given immediately with little worry for legal ramifications.

So if she was under 18, say 15, and she had the same card in her purse, would it be overriden because she is not legally able to make that decision? And the state could take custody of her because she is a minor?

Or, if she was a minor, and her parents said, "Hey no we're JW, don't give her the transfusion," physicians could do it anyway?

 

[tn4596]

So if she was under 18, say 15, and she had the same card in her purse, would it be overriden because she is not legally able to make that decision? And the state could take custody of her because she is a minor?

Or, if she was a minor, and her parents said, "Hey no we're JW, don't give her the transfusion," physicians could do it anyway?

Yea if the person is a minor then you will have more leeway. Maybe getting a court order, I am sure any hospitals will have ethics/legal professionals there to help you out.

 

[hobbity]

So if she was under 18, say 15, and she had the same card in her purse, would it be overriden because she is not legally able to make that decision? And the state could take custody of her because she is a minor?

Or, if she was a minor, and her parents said, "Hey no we're JW, don't give her the transfusion," physicians could do it anyway?

To my understanding - if she is under 18, the doctors could give the transfusion without legal ramification.

Since the card was recently signed, the doctors don't have a reason to suspect that her opinions might have changed in between the time she signed it and when she was in the hospital... so I don't think they're supposed to give a transfusion (though they'd have to call the family).

I have a question as well - would the signed Jehovah's Witness Card count as an advance directive? (or, maybe put in a different way, does it carry the same weight as an advance directive?)
Also, if the card was signed before her 18th birthday, would the doctors be able to give the transfusion (since she would have been considered unable to make that sort of decision at the time)?

 

[darkjedi]

So if she was under 18, say 15, and she had the same card in her purse, would it be overriden because she is not legally able to make that decision? And the state could take custody of her because she is a minor?

Or, if she was a minor, and her parents said, "Hey no we're JW, don't give her the transfusion," physicians could do it anyway?

To my understanding it is both. At least in PA, blood transfusions can be given as soon as it's needed and a court order can be applied retroactively.

 

[MI Achilles]

To my understanding - if she is under 18, the doctors could give the transfusion without legal ramification.
Also depending on the state she the PT resides in; prisoners also.
Since the card was recently signed, the doctors don't have a reason to suspect that her opinions might have changed in between the time she signed it and when she was in the hospital... so I don't think they're supposed to give a transfusion (though they'd have to call the family).

I have a question as well - would the signed Jehovah's Witness Card count as an advance directive? (or, maybe put in a different way, does it carry the same weight as an advance directive?)
Also, if the card was signed before her 18th birthday, would the doctors be able to give the transfusion (since she would have been considered unable to make that sort of decision at the time)?

I did some reading on this subject and it is a little confusing.
It is up to the decision of the PT whether or not they recieve white blood cells, red blood cells, and platelets. However it is unacceptable for the PT to recieve plasma.

 

[Microshaft]

The more I learn about this world, the stranger it seems...

 

[circulus vitios]

This isn't a hard question or even remotely controversial. There is a right and there is a wrong answer. If you can't get this right, there is something wrong.

Call the hospital's lawyer.

 

[msamp]

No need to worry. Give a blood less transfusion. It doesn't go again Jehovah Witness' religious beliefs and it is allowed.

 

[Law2Doc]

I'm sorry if I'm sounding stupid here, but I'd like an explanation on the answer to not give her the transfusion.

Is the card legally binding? I feel like there might be even worse legal ramifications if the physician did not do it (assuming there is no legal meaning in the JW card). I would say that it's a naive 18 year old who just made a recent decision on something that she might not even stick with. It would be my job as a physician to keep her alive and a recent decision made by her shouldn't cost her her life. If she wakes up and feels like she was wronged, then fine, she'll eventually realize that I'm the monster, not her, but at least she's alive. I would be fine with being the bad guy if I didn't let someone die over some decision that was made a few weeks ago.

This is assuming that there will be no legal problems afterwards.

In this country, there is no such thing as a "naive 18 year old " exception. Once you reach the age of contractual majority (18), you are an adult. If you decide that your religion forbids transfusions, and you have something on your person that provides good evidence of that, the doctors will respect your autonomy. I've seen many JW patients die in the ICU because they lost too much blood or because no surgeon was willing to try a necessary procedure on them without blood. it's a group of people who choose their faith over known lifesaving options of modern medicine.

 

[mimelim]

In this country, there is no such thing as a "naive 18 year old " exception. Once you reach the age of contractual majority (18), you are an adult. If you decide that your religion forbids transfusions, and you have something on your person that provides good evidence of that, the doctors will respect your autonomy. I've seen many JW patients die in the ICU because they lost too much blood or because no surgeon was willing to try a necessary procedure on them without blood. it's a group of people who choose their faith over known lifesaving options of modern medicine.

I have had 1 patient die this year and 2 patients suffer major morbidities as a direct result of their refusal of blood products. This is something most physicians will deal with on occasion. Which is why people should really understand this stuff before ever setting foot in a hospital.

This is a very clear cut case and goes to the core of medical ethics. It isn't meant to be tricky. There are no questionable factors and no ambiguity (something you generally don't have the benefit of in the real world). By the textbook, it is morally, ethically and legally wrong to give a transfusion or any other medical care to a patient that you know does not want one. You do not get to judge the patient for their decisions and impose your beliefs on them. You are obligated from a moral, ethical and legal standpoint to explain the risks and benefits of any intervention to be best of your ability and advocate for what you think would benefit the patient the most or decrease the chances of something bad would happen. But at the end of the day, autonomy is paramount.

Before interviewing you should understand the following concepts and be at least familiar with the textbook examples of each:

Autonomy
Beneficence
Non-maleficence
Justice
Respect
Honesty

 

[Geebeejay]

Dr. House would give the transfusion

 

[BABSstudent]

No immediate transfusion in my opinion. Everything points to the patient not wanting it. Why save their life now if they believe they will face eternal damnation for that action.

I would check to see if there was something else we could do that would follow her religion. Maybe sedate the patient and use saline to return blood volume and reduce oxygen need and buy some time. Maybe her body could replace the blood given time. If the patient comes to and says she doesn't want treatment then I wouldn't do anything. If this doesn't give time and the patient will die, I still wouldn't do anything. I can't deny them their culture and decisions that all signs point to her wanting to do.


Sent from my iPod using SDN Mobile app. Please excuse the typos.

 

[K31]

I'm sorry if I'm sounding stupid here, but I'd like an explanation on the answer to not give her the transfusion.

She's an adult, so she has a right to make stupid decisions about her health based on superstition.

 

[eefen]

She's an adult, so she has a right to make stupid decisions about her health based on superstition.

Lol....that's one way to put it, I suppose.

Situations like these are tough. But, in the case of adults with known wishes, patient autonomy should be preserved....even if we disagree.

 

[saveourpens]

Just fyi, a question almost identical to this is standard at a certain med school.

 

[dsoz]

I have had 1 patient die this year and 2 patients suffer major morbidities as a direct result of their refusal of blood products. This is something most physicians will deal with on occasion. Which is why people should really understand this stuff before ever setting foot in a hospital.

This is a very clear cut case and goes to the core of medical ethics. It isn't meant to be tricky. There are no questionable factors and no ambiguity (something you generally don't have the benefit of in the real world). By the textbook, it is morally, ethically and legally wrong to give a transfusion or any other medical care to a patient that you know does not want one. You do not get to judge the patient for their decisions and impose your beliefs on them. You are obligated from a moral, ethical and legal standpoint to explain the risks and benefits of any intervention to be best of your ability and advocate for what you think would benefit the patient the most or decrease the chances of something bad would happen. But at the end of the day, autonomy is paramount.

Before interviewing you should understand the following concepts and be at least familiar with the textbook examples of each:

Autonomy
Beneficence
Non-maleficence
Justice
Respect
Honesty

+1 I recently had an MMI with a non-disclosure agreement, so I can't say anything about the actual case. The actual scenario was completely different from the one described by the OP, but the underlying ethical dilemma was still there.

There was an initial situation. I was asked "what would you do if in this situation?"

The conditions were changed a little, "does this affect your answer that you gave before?"

The conditions were changed in a different way (but returned the basic situation back to the original stated) and "does this affect your answer that you originally gave?"

The ethics behind the situation were very clear cut, right/wrong from the list that was given above (Autonomy, Beneficence, Non-maleficence , Justice, Respect, Honesty). IMO, one of the secondary conditions changed the situation (power of attorney), but the other one did not (cultural differences). I think that this is ambiguous enough to fit within my NDA. If not, I can remove some of it.

I only have been on five interviews, three with MMI stations. There was only one with an ethical question posed like this. It is important to know some ethics going in, but it won't be on every interview that is experienced.

dsoz

 

[TheMaverick]

What if the patient may have made that decision under duress? I highly doubt an 18 year-old child of JW parents could opt out of their religion without severe repercussions.


What do you think of loop-holing the anti-transfusion religious stricture so you can give her the blood without violating the card?

 

[BABSstudent]

What if the patient may have made that decision under duress? I highly doubt an 18 year-old child of JW parents could opt out of their religion without severe repercussions.


What do you think of loop-holing the anti-transfusion religious stricture so you can give her the blood without violating the card?

How do you plan on proving it was signed under duress?

And how do you plan on loop holing her religious views? Sounds like you need to experience new cultures and have your views be the odd one. If she had a card refusing medical treatment then you shouldn't provide that treatment.

For example, if a patient has a DNR, do you attempt to provide life saving technique even though the patient asked not to have it? This situation is not different. An adult made a decision and doesn't want treatment.


Sent from my iPod using SDN Mobile app. Please excuse the typos.

 

[TheMaverick]

How do you plan on proving it was signed under duress?

And how do you plan on loop holing her religious views? Sounds like you need to experience new cultures and have your views be the odd one. If she had a card refusing medical treatment then you shouldn't provide that treatment.

For example, if a patient has a DNR, do you attempt to provide life saving technique even though the patient asked not to have it? This situation is not different. An adult made a decision and doesn't want treatment.

That's part of the issue, we don't know why she signed it, only that she did. If this were an 81 year old rather than an 18 year old, I would be a lot more confident that their medical decisions had been made in an informed and free manner. That's much of why I'm considering a course of action that would give her proper medical care while technically not violating her card.

In my experience, its very hard to make rules without unintended exceptions. In this case, I haven't looked at JW religious laws so I can't say what these exceptions would be. Perhaps, since christians do not keep Jewish dietary restrictions which include drinking blood (and have, indeed, ritualized drinking "blood") a loophole could probably be transfusion through somewhere the GI tract, since that wouldn't be transfusion but "eating." Btw, I have a great many experiences with other cultures and often have my views be the odd one out.

 

[GomerPyle]

This is a very tough situation. As a doctor, your duty is to save lives. I don't think you can base your decision off of a "card". You have to receive a verbal confirmation from the patient that she does NOT give consent for treatment. Since she is unconscious, you do not have proper refusal of treatment so I would probably give the transfusion. If there is a close family member (such as a father, or a husband), than I would ask them for consent.

This is my personal opinion. Anything wrong with this?

 

[TheMaverick]

This is a very tough situation. As a doctor, your duty is to save lives. I don't think you can base your decision off of a "card". You have to receive a verbal confirmation from the patient that she does NOT give consent for treatment. Since she is unconscious, you do not have proper refusal of treatment so I would probably give the transfusion. If there is a close family member (such as a father, or a husband), than I would ask them for consent.

This is my personal opinion. Anything wrong with this?

I think the bolded part might be an oversimplification. As a doctor, I think your responsibility is to use your skills and knowledge to help patients reach their health goals, although there is a baseline assumption that these goals would be improved health. That's why informed consent is generally required and a patient can refuse care. However, since doctors are driven "to save lives" (that's why most doctors are doctors), there is bias towards doing so. That's why you're setting such a high threshold for refusal of treatment.

In regards to your question, I think the card constitutes sufficient refusal of care, so you should not give the transfusion.

 

[mimelim]

This is a very tough situation. As a doctor, your duty is to save lives. I don't think you can base your decision off of a "card". You have to receive a verbal confirmation from the patient that she does NOT give consent for treatment. Since she is unconscious, you do not have proper refusal of treatment so I would probably give the transfusion. If there is a close family member (such as a father, or a husband), than I would ask them for consent.

This is my personal opinion. Anything wrong with this?

It is not your duty to save lives. That is a TV show mentality, not an ethical, moral or legal one. Your duty is to your patient. You have proper refusal of treatment on a well recognized form that was recently signed. Why talk to family when you have the patient's wishes spelled out for you? Family members are instructed (though they do not always follow this) to do what they think the patient would want.

Giving a transfusion to this patient is wrong. You are not respecting their autonomy which is again, ethically, morally and legally wrong.

 

[sunflower18]

I agree with the prevailing sentiment in this thread. Although it'd break my heart to watch a patient die from a completely fixable situation, it is not the job of a doctor to play god. Doctors cannot simply treat however they deem best without the consent of the person they are treating. Like was said, it is a doctor's job to provide care for a patient in the way the patient agrees to, and respect his/her decisions about his/her own life and rights.

 

[syoung]

^1 +1.

Does that mean it's squared? But I like mimelim's answer, considering he's both a resident and doctor.

 

[Geebeejay]

This is a very tough situation. As a doctor, your duty is to save lives. I don't think you can base your decision off of a "card". You have to receive a verbal confirmation from the patient that she does NOT give consent for treatment. Since she is unconscious, you do not have proper refusal of treatment so I would probably give the transfusion. If there is a close family member (such as a father, or a husband), than I would ask them for consent.

This is my personal opinion. Anything wrong with this?

You actually have no choice ethically but to base your decision off of a "card", because the card is the choice of the patient. Might want to get a legitimate document expressing her wishes, but only to protect yourself legally when she dies because she didn't get transfused, and definitely do not transfuse her until you hear otherwise from her or her family. As long as the patient is competent to make her own medical decisions at the time she made them, she can make however dumb of a decision she'd like.

 

[Thego2guy]

Disclaimer: I'm not a serial killer

This would be an interesting way to kill someone. I've never seen one of those cards, but I can imagine some elaborate murderer getting a hold of one... dangerously hurting the victim (severing a major artery?), signing the card with a fake signature, and inserting it into the victim's purse while they are unconscious. Physicians would find the card, assume the signature is legit, refuse transfusion, and pt dies...

I'm so freaking paranoid of this stuff lol.

 

[ScholarStud]

Disclaimer: I'm not a serial killer

This would be an interesting way to kill someone. I've never seen one of those cards, but I can imagine some elaborate murderer getting a hold of one... dangerously hurting the victim (severing a major artery?), signing the card with a fake signature, and inserting it into the victim's purse while they are unconscious. Physicians would find the card, assume the signature is legit, refuse transfusion, and pt dies...

I'm so freaking paranoid of this stuff lol.

You don't have much to worry about. If someone goes through the trouble of severing a major artery they are probably more than willing to finish the job.

I would also like to state, that I am in fact, not a serial killer.

 

[def1]

Disclaimer: I'm not a serial killer

This would be an interesting way to kill someone. I've never seen one of those cards, but I can imagine some elaborate murderer getting a hold of one... dangerously hurting the victim (severing a major artery?), signing the card with a fake signature, and inserting it into the victim's purse while they are unconscious. Physicians would find the card, assume the signature is legit, refuse transfusion, and pt dies...

I'm so freaking paranoid of this stuff lol.

lol thats a ridiculous situation. What would be the purpose of going through all that trouble?

Anyways, patient's choice always trumps what the doctor wants to do. Which is why I wish euthanasia wasn't illegal. Hopefully I don't get flamed for that opinion.

 

[487806]

It is not your duty to save lives. That is a TV show mentality, not an ethical, moral or legal one. Your duty is to your patient. You have proper refusal of treatment on a well recognized form that was recently signed. Why talk to family when you have the patient's wishes spelled out for you? Family members are instructed (though they do not always follow this) to do what they think the patient would want.

Giving a transfusion to this patient is wrong. You are not respecting their autonomy which is again, ethically, morally and legally wrong.

Well, thanks for clarifying the misconception. Also, mimelim or sector9 or others, would it be best to study behavioral science as a way to prepare for these questions? I would definitely get this question wrong due to my ignorance.

 

[487806]

Pretty sure patients still have their autonomy, even in emergent circumstances

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

 

[Thego2guy]

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

To my knowledge they usually resect something if they see it.. if not for treatment purposes, then definitely for biopsy.

And to answer the question about my statement, why go through all of that trouble....

idk.. if you eff em up badly by staging a situation where it looks like an accident, and you shadow them, see them lose consciousness, and add the card to the purse...then you might have less of a guilty conscious because technically, they were very well alive when you left them. It is the physician's lack of action that killed the victim... so the murderer might have an easier time reasoning through it.

At least that is how I would do it............

 

[mimelim]

Well, thanks for clarifying the misconception. Also, mimelim or sector9 or others, would it be best to study behavioral science as a way to prepare for these questions? I would definitely get this question wrong due to my ignorance.

I don't think you need to study (take a class) on this. Read a couple books on medical ethics, even the popular press ones are pretty good. You must understand the basic principles which is nothing more than learning definitions. These have standard cases associated with them. This case is a classic example. Then you have to go the step further and understand what modifications do to your situation. What if the patient was underage, pregnant, competing documents, family situations, no card but family says something to the affect of that card, etc. You don't have to be an expert to know what to do in each of those. Ethics are tricky in the real world sometimes. Just be sure that you don't screw up the classics, especially in interviews, because in both interviews and real life, you will get nailed for it.

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

Unwarranted or unwanted? Most people would say that if a surgeon found an unrelated tumor, most would want it taken out. If you do not consent your patient for that procedure, you should not be doing it. Now, I see on a weekly case this being bent. Most of the time we consent our patients for "Lap chole, possible open chole and all other indicated procedures". When I talk to patients about the procedures I tell them that sometimes we find unusual things when we are in surgery which require us to change our plans. I usually think it is a cop out and I don't know how much it actually covers us since it IS overly broad.

 

[Bacchus]

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

Unless extraneous findings are covered on consent, then they cannot be touched. Hence, why sometimes broad terms such as exploratory laporotomy are used.

A surg res/attending can correct me if wrong.

 

[Ashley1989]

What about unwarranted surgical procedures? If a patient is scheduled for an operation, and along the way, the doctor found an unrelated tumor. Would it be right for the doctor to remove the tumor?

I don't know much about policy or anything for that matter, but wouldn't further tests be needed first? And a surgical "gameplan" to make sure they can plan the least abrasive surgery with the least possible complications for the patient?