so what is the most correct answer to the blood transfusion question?

[rocketbooster]

I just finished my interview and my 2nd interviewers were very persistent with the Jehova's witness blood transfusion question.

I first said, "I would take the case to the hospital's ethics committee, that's what they're for. it could go as far as the courts from there and the parents could be overruled." so then they rephrased the question to "what would you do if the child needs the blood transfusion right then or they'll die? they don't have time to reach the ethics committee." we debated back and forth and finally I said "I do not have the right to give the child the blood transfusion if the parents are saying no." so then they said "you would let the child die!?!?" I answered "I don't want the child to die, but it's out of my hands. I would tell the parents that medically here is what you need to do to save your child's life, but ultimately it's up to the parents right there on the spot despite if I think they're wrong." they were still questioning me until I gave a real-life example in which the parents were overruled by a court because they deemed the case child abuse." that made both of the interviewers utter a "wow..." since the story I gave was pretty intense. they dropped the question after that.

did I handle that right or no? I probably didn't but I didn't want to change my answer half way through the interview. they also asked at some point "what would you do if I was in the ER as the patient and I wanted to get up and leave." I was like "...by yourself?" he said "no, with my wife." i said "well, if you don't want treatment and want to leave the hospital that is your choice. i would insist you stay but I can't force you to." I don't know...these interviewers were really driving my patience.

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[Depakote]

Tough situation to be but in, but IIRC everything (legally) supports you giving the transfusion in this case.

the argument goes something like:
The child isn't old enough to make the decision on their own and the parents don't have the right to martyr their child for a religion that they haven't had a chance to accept.

 

[rocketbooster]

Tough situation to be but in, but IIRC everything (legally) supports you giving the transfusion in this case.

the argument goes something like:
The child isn't old enough to make the decision on their own and the parents don't have the right to martyr their child for a religion that they haven't had a chance to accept.

awesome. looks like that's a rejection. i thought this ethical questions did not have a correct answer? based on what you said, clearly it did have a correct answer. how is a pre-med student supposed to know what the IIRC legally supports? ughhhh

 

[rocketbooster]

actually, could you show me legally where they support such a case?

because I have read plenty of literature saying you have to follow the surrogate's wishes despite if you agree with them or not.

just as you said the parents shouldn't have a right to decide for their child who has not accepted the religion...why do you legally have the right as a doctor to decide for the child? the parents should have more power over their own children than the child's doctor. it isn't your child but theirs. personally, I would want to save the child but I think it's still up to the parents. I feel, depending on the case, the IIRC would legally support either option depending on the circumstance. please correct me if I am wrong.

 

[Gut Shot]

The accepted course of action varies somewhat from state to state. In Virginia it's pretty straightforward: an on-call judge is contacted to order the transfusion. I've never had to deal with it personally, but those I know who have say the parents are usually relieved that the decision is not theirs anymore. Since the procedure is done against their wishes, the religious ramifications are also mitigated. Everyone wins.

 

[rocketbooster]

The accepted course of action varies somewhat from state to state. In Virginia it's pretty straightforward: an on-call judge is contacted to order the transfusion. I've never had to deal with it personally, but those I know who have say the parents are usually relieved that the decision is not theirs anymore. Since the procedure is done against their wishes, the religious ramifications are also mitigated. Everyone wins.

good to know.

and for the first poster. i don't know your qualifications other than SDN says you're a med student. I've asked this question to many doctors who have been practicing for 15+ years and they have all said you usually cannot do anything. so I'm going to go with their opinion over yours. you don't have any real experience yet.

sorry if that sounds like I'm flaming you! i'm just trying to make myself feel better. i need to be more confident.

oh and to the above poster, i wish i knew your scenario earlier. that would have shut them up to begin with. the 2nd interviewers were a clinical researcher with a PhD and an M4. when have they been put into a real-life scenario when they had to make that kind of decision? they haven't. when I gave them that real-life example, they were speechless and gave up.

anyways, I'm just saying you can probably argue it either way. I think I'm content with how I mentioned it.

 

[Depakote]

actually, could you show me legally where they support such a case?

because I have read plenty of literature saying you have to follow the surrogate's wishes despite if you agree with them or not.

just as you said the parents shouldn't have a right to decide for their child who has not accepted the religion...why do you legally have the right as a doctor to decide for the child? the parents should have more power over their own children than the child's doctor. it isn't your child but theirs. personally, I would want to save the child but I think it's still up to the parents. I feel, depending on the case, the IIRC would legally support either option depending on the circumstance. please correct me if I am wrong.

I suggest you stop worrying about the interview since it's past, but here's a good case report:

http://www.ncmedicaljournal.com/sep-oct-07/brezina.pdf

 

[silverlining1]

I've asked this question to many doctors who have been practicing for 15+ years and they have all said you usually cannot do anything.

I was also asked this - before making a decision, I asked my interviewer if there is already a law governing this type of situation (hey, I admit, I'm not extremely well informed about this kind of thing). He told me that the patient, or in this case, the parents have the right to refuse treatment. I said that it would feel awful but if the law requires me to respect the parents' wishes, I would do as they requested and not do anything behind their back. Response: "Good answer."

 

[Bacchus]

Good read, Dep.

 

[rocketbooster]

I suggest you stop worrying about the interview since it's past, but here's a good case report:

http://www.ncmedicaljournal.com/sep-oct-07/brezina.pdf

okay, nice. thanks. that states the law will back up a doctor if he/she decides to go against the parents' wishes. it does not say the doctor is obligated to go against the parents' wishes, though. it just gives guidelines on how the doctor should make the decision on whether or not they should respect the parents' wishes. in either case, having been able to cite your article in my interview would have made me look badass. did you really have this info, though, when you were a pre-med student interviewing at med schools? Probably not...hehe. but whatever...my answer wasn't wrong, though.

so, clearly, there is more than one answer. look at these replies. there are both sides to the argument supported by different people.

Dep, I apologize if I offended you. I am just frustrated with those interviewers because they made such a big deal about it. I just felt like they could have asked more questions in their 30 minutes rather spending 20 minutes of it on one question. I was getting annoyed and wanted to cuss them out. Don't worry, I didn't, though hehe.

 

[Excelsius]

I think that this question is asked not to find out whether you are a law abiding citizen, but to reveal your character. It is safe to assume that the student will not know the exact laws pertaining to the procedure. Even lawyers might not know because ethics is complex (one of my friends who is a lawyer told me that her hardest class in the law school was the ethics class) and the laws vary from state to state.

Therefore, it all comes down to character. Either answer can be positive or negative. Perhaps choosing to save the life will be more positive, but in certain cases, you can give a positive answer while choosing death - silver's example illustrates this well.

Some might disagree, but your job as a doctor is to save the person's life. If the child is in your care, then you are responsible for it and the transfusion should be given even if the parents disagree. First, the child is too young to decide for himself, and second, if the parents want you to stand there and watch their child die, then they should have not brought him to the hospital in the first place. If you're a fanatic religionista trying to kill your child, what are you doing in a hospital? Third, if the emergency requires action within few minutes, parents might not even be notified about a transfusion because the doctor's job is to save the child first, and act as a harbinger second.

I'd love to see the case go to court: "Doctor is being sued by the parents for not letting their child die." The case will be laughed out of the court in many locales. This is 21st century, not the medieval inquisitional republic.

And by the way, what happened to those "pro-life" arguments? I mean if using contraceptives or aborting a bunch of cells is considered "murder" since the "child" can't decide, what about the older child requiring transfusion? We are always on the brink of making abortion illegal. The denial of transfusion by anyone other than the child is what needs to be illegal. Are we dumb or what? And this is religion. Perfect!

 

[mmmcdowe]

The legal answer: You can't do anything

What any veteren doctor (especially with tenure or a similar situation) would do: save the kid, **** the parents and their religion.

That doesn't answer your question, however, because just because a doctor would brake the rules doesn't mean they want you to... I, fortunately haven't had this question.

Real life story from my dad:

Had a patient, refused to be treated for a deadly condition that could be fixed because of his religion, but wanted to be made unconscious while he died. My dad declared he unfit to make decisions as soon as he passed out, saved his life.

Now just a disclaimer, he's an ER doc, and the patient had in by someone on his own free will. Hospital stood behind him, said he had willingly come in, and therefore the treatment was acceptable. No DNR or anything.

 

[eagle34]

USLME type questions from Barbaba Fadem, who actually contributes to writing questions on behavior science for USLME.

1) Clearly competent 50-year old women who has religious beliefs that preclude blood transfusion is scheduled for surgery, and says she doesn't want blood transfusion. If a transfusion becomes necessary during surgery, the physician should replace lost body fluids but not give the woman the transfusion.

Compare to:

2) 30-year old man and his 10-year old son are injured in train crash. Both of them need surgery within next 12 hours. Father is clearly mentally competent but refuses surgery, for religious reasons, for both himself and his son. The physician should get a court order for the surgery on the child but do not operate on the father.

This issue has to do legal competence. Even though a legal competent adult has the right to refuse any treatment. However, if a child is in serious danger (we're talking life and death - like emergency transfusion), the child is not legally competent to make a decision, and it's the parents who make the decision for the child; however, if these decisions put the child in grave danger, the doctor has a right to act to save the child's life, even if it means disobeying parents' wishes.

 

[lord_jeebus]

This is a classic medical boards question, and in that context the correct answer is to transfuse the child.

 

[ANF1986]

I used to be a Jehovah's Witness...If they have a signed card in their wallet which clearly states they refuse blood, I believe that your hands are tied. Of course, in an actual situation, you might choose to "lose" the card, and I wouldn't blame you. It was a policy I never really agreed with, as you can tell by me saying "used to" lol...

ohh yea p.s.- there are a lot of bloodless alternatives now, you could research them for your future interviews and throw those at the interviewers as well. A lot of people I know who still practice the faith goto one particular hospital nearby which has a big bloodless surgery program whenever they need serious procedures done. My grandfather had a hip replaced at this hospital and refused blood for his surgery, the surgery went well regardless of not accepting transfusion.

 

[Excelsius]

This is a classic medical boards question, and in that context the correct answer is to transfuse the child.

Glad to hear that medicine is not completely invaded by religion. I hope things will get better in the next eight years under rational national leadership.

Lord, when you say "in that context," it makes me assume that there is another context where it is ok to let the child die. Does that include anything other than the child's own consent? If not, how is it justified to let a young child die just because parents feel like it? Are you aware of any such cases (specific names)?

 

[lord_jeebus]

I used to be a Jehovah's Witness...If they have a signed card in their wallet which clearly states they refuse blood, I believe that your hands are tied.

This is true - if the patient is competent to make their own medical decisions. I watched a Jehovah's Witness slowly bleed to death in the ICU just a couple of months ago.

But younger children are a different story and their parents can't make that choice for them.

 

[lord_jeebus]

Glad to hear that medicine is not completely invaded by religion. I hope things will get better in the next eight years under rational national leadership.

Lord, when you say "in that context," it makes me assume that there is another context where it is ok to let the child die. Does that include anything other than the child's own consent? If not, how is it justified to let a young child die just because parents feel like it? Are you aware of any such cases (specific names)?

I meant in the context of board exams.

Outside of the boards, I think it should be the same, but evidently (judging from this thread) there is some controversy.

 

[ANF1986]

This is true - if the patient is competent to make their own medical decisions. I watched a Jehovah's Witness slowly bleed to death in the ICU just a couple of months ago.

But younger children are a different story and their parents can't make that choice for them.

The card is supposed to apply whether the patient is concious or unconcious (assuming they are 18 years old).

However I think its becoming more of a non-issue, since JW's can now accept hemoglobin... As referenced by the AJWRB:

The Watchtower Society has officially notified its members (see diagram from 6-15-04 Watchtower) that they may now use hemoglobin (red cells without the membrane) - the largest of all blood components which transports oxygen throughout the body. We welcome these developments.

If you are interested in court cases... you reference

Parham v. JR (US Supreme Court)

In re Hofbauer (NY Supreme Court)

 

[lord_jeebus]

The card is supposed to apply whether the patient is concious or unconcious (assuming they are 18 years old).

I mean, competent when they sign the card, not when they arrive.

 

[ANF1986]

Also if you really wanna impress them, you can tell them what Jehovahs Witnesses find acceptable and unacceptable..:

 

[rocketbooster]

okay, everyone, look at these replies. every other reply says something different and each person claims it is FOR SURE their way.

I think it's safe to conclude there is no conclusive answer to this question. while I know many of you being med students and residents are way more qualified than myself and claim you are obligated to save the child, I have asked numerous practicing for 15+years docs who say you cannot do anything. who is correct? I would go with the experienced docs, but I also see Dep's article, which seems very legit, claiming otherwise. I think as long as you stick with your same answer throughout your interview, then you are good. agreed or no?

 

[Gut Shot]

Also if you really wanna impress them, you can tell them what Jehovahs Witnesses find acceptable and unacceptable..

This confuses me. Hemoglobin is a protein that will not function in a useful manner unless it is within red cells, so you cannot simply administer hemoglobin. Virtually all blood products are fractionated into red cells, platelets and plasma, although none of those fractions are pure. Are you saying that JWs will now accept red cell fractions?

 

[Gut Shot]

I have asked numerous practicing for 15+years docs who say you cannot do anything. who is correct?

You cannot do anything... unless you are willing to get a judge involved. That's where it's up to you whatever precedents exists in your state and in your institution.

 

[rocketbooster]

You cannot do anything... unless you are willing to get a judge involved. That's where it's up to you whatever precedents exists in your state and in your institution.

I agree with you, but why are all these people saying otherwise? 🙁

 

[lord_jeebus]

This confuses me. Hemoglobin is a protein that will not function in a useful manner unless it is within red cells, so you cannot simply administer hemoglobin. Virtually all blood products are fractionated into red cells, platelets and plasma, although none of those fractions are pure. Are you saying that JWs will now accept red cell fractions?

I think he's talking about polyheme.

Incidentally, although I haven't looked into it, I don't know of any evidence supporting polyheme or other artificial blood product alternatives, although I know their are current clinical trials of some sort.

 

[Gut Shot]

I agree with you, but why are all these people saying otherwise? 🙁

I don't know. The mantra at my medical school was "call the judge, transfuse the kid."

 

[Gut Shot]

I think he's talking about polyheme.

Incidentally, although I haven't looked into it, I don't know of any evidence supporting polyheme or other artificial blood product alternatives, although I know their are current clinical trials of some sort.

His flow chart suggests otherwise, at least to me. They've been mucking around with blood substitutes for decades. Still no cause for celebration.

 

[lord_jeebus]

I think that in real life, most would call a judge first, unless the delay would threaten the child.

The principles here aren't that complex.

Competent adults can refuse any treatment they want for any stupid reason.

Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

 

[rocketbooster]

I think that in real life, most would call a judge first, unless the delay would threaten the child.

The principles here aren't that complex.

Competent adults can refuse any treatment they want for any stupid reason.

Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

That's not what Gut, a resident like yourself, said. He said the opposite. Who is correct? I honestly do not know. I'm sticking with the doctors I've asked who have been practicing for 15+ years. However, I'm sure we all live in different states. Perhaps in your state, it's clear that you can override the parents without consulting a judge.

 

[medking]

That's not what Gut, a resident like yourself, said. He said the opposite. Who is correct? I honestly do not know. I'm sticking with the doctors I've asked who have been practicing for 15+ years. However, I'm sure we all live in different states. Perhaps in your state, it's clear that you can override the parents without consulting a judge.

Sheesh. Chill out man. Throughout all of your posts in this thread, you seem so defensive about your answer. I would make sure this doesn't show during your interview cause the answer is not what they're necessarily looking at.

No worries, your answer is fine. Just make sure you know some cases to back your stance.

 

[Bacchus]

I couldn't live with myself if I didn't override the parents. I'd worry about the judge later.

 

[mdmarty]

• Competent adults can refuse any treatment they want for any stupid reason.
• Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

QFT. It's really quite simple.

 

[SiR99]

I think that in real life, most would call a judge first, unless the delay would threaten the child.

The principles here aren't that complex.

Competent adults can refuse any treatment they want for any stupid reason.

Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

This makes perfect sense

Dont come on this forum and post a question if you can not deal with the answer.

If the parent present is psychotic or mentally ill, do you still think a judge would allow them to make decisions for the child? No

A parent refusing to save their childs life shows that there is something wrong with that parent, and so no judge would allow a parent like that to make decisions for anyone.

 

[mmmcdowe]

I think that in real life, most would call a judge first, unless the delay would threaten the child.

The principles here aren't that complex.

Competent adults can refuse any treatment they want for any stupid reason.

Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

This is correct. I think what some of your confusing has been OP is that people are saying that you can't just do it, because you are supposed to get an order from a judge first.

 

[ANF1986]

Most of the bloodless surgery seems to be done by starting the patient on EPO far in advance of of the procedure. I'm not familiar with what is used in cases of trauma..

 

[Calf]

Also if you really wanna impress them, you can tell them what Jehovahs Witnesses find acceptable and unacceptable..:

I was raised a Jehovah's Witness and my parents still are practicing members. The above is correct.

 

[ANF1986]

I was raised a Jehovah's Witness and my parents still are practicing members. The above is correct.

Same here but I dont practice at all, in any shape or form anymore...Thats interesting, didnt know there were that many heathens out there like me, lol...

 

[Narmerguy]

That's not what Gut, a resident like yourself, said. He said the opposite. Who is correct? I honestly do not know. I'm sticking with the doctors I've asked who have been practicing for 15+ years. However, I'm sure we all live in different states. Perhaps in your state, it's clear that you can override the parents without consulting a judge.

You need to calm down a little. We understand, you've talked to doctors about this who have practiced 15+ years etc etc. What's been said has been said and it's up to the adcoms now. You need not harrass everyone who responds about their views or opinion.

 

[WannaBePreMed]

I think that in real life, most would call a judge first, unless the delay would threaten the child.

The principles here aren't that complex.

Competent adults can refuse any treatment they want for any stupid reason.

Parents can not prevent their children from receiving life-saving care, no matter their reasoning.

So can a doctor save the child's life before the judge overrules the parent's decision or must they wait for the judge?

 

[mmmcdowe]

So can a doctor save the child's life before the judge overrules the parent's decision or must they wait for the judge?

No doctor is going to wait, no judge is going to convict them.

 

[Gut Shot]

I couldn't live with myself if I didn't override the parents. I'd worry about the judge later.

Perhaps it was just my institution in just my state, but they had a judge on-call 24/7. Approval could be obtained before the units even made it to the floor or ER, so there was no delay. There are other instances where a judge's order is necessary to provide appropriate care, so it just made sense.

 

[LizzyM]

Thus far,all the polyheme trials have failed to show a benefit (and some have even shown evidence of harm).

Because the product is made from blood, many people who object to blood transfusions on religious grounds will not accept it. There were opt-out mechanisms in some polyheme trials so that those individuals would not be enrolled as subjects in emergency situations.

 

[rocketbooster]

Ok, sorry if I came off harsh last night.

And no, I didn't mention the "15+ year practicing doctors saying they could do nothing" during the interview. That's just what I was telling myself in my head to make myself stay with my initial answer the whole time. And, you're right, just knowing cases to back yourself up is the important part. Once I gave a real case they finally backed off.

I was posting last night right after I finished my interview and I was frustrated how adamant they were about that question. They spent 20 of the 30 minutes on it, heh. So, since I obviously couldn't vent at the interviewers, I went off on some of you. I apologize. 🙂

Thanks for all your responses! Thread closed!

 

[Retsage]

If you are 18+, you can refuse whatever treatment you want.

If you are below 18, your parents cannot refuse treatments if they put you in grave danger.

Pretty straight-forward.

 

[JeetKuneDo]

Someone once tried to convert me to become a JW....

 

[PeepshowJohnny]

In short you ALWAYS transfuse a minor. The courst have shown that parents have zero right to refuse life saving treatments for a child. The gray area is where you get kids refusing possibly life saving treatments (like teenagers wanting to refuse chemotherapy when it's not a guarantee cure) but that usually requires special court preceedings. But stuff like parents refusing admissions, blood transfusions, antibiotics, insulin, you're in the right to override parents objections for religious or any other nonmedical reason.

The other situation is where a woman brings in a manbleeding out and she screams "He's a Jehovah's Witness! No blood!" In this situation, where there's no proof that he is or isn't (outside of one person saying he is) you have to transfuse because you don't know the social situation (I.e. he may not practice and this person is his sister and concerns about his soul.) That's why they all carry the cards to certify.

 

[kac714]

alot of it also varies by state. read the article depakote posted, it nicely sums the issue up. granted, in that case the child was older.

 

[efitzpat]

The Supreme Court Ruling Says "Parents may be free to become martyrs themselves, but it does not follow that they are free, in identical circumstances, to make martyrs of their children."

Judges are on call 24/7 and they can be called and an order should be put through immediately.

On the other hand, I shadowed a hemotologist at CHildrens LA and he was an expert on dealing with Jehovah's Witnesses (he is the foremost expert in So Cal and often received calls form all over). So it wouldn't hurt - in a nonemergent situation - to practice culturally sensitive medicine and have a mediator of sorts help with the family decision.

That would be my answer

 

[stoic]

why am i posting here?

well, here is why.

people live and people die. everyday.

if you have the balls to go against the parents wishes... well, then you have the balls to have yourself sued and sued and sued. and part of that is modern medical practice.

but ultimately, you cannot treat a minor without the parents consent. and if they are fanatic enough, they will be able to put it up your rear end in EVERY court in the nation.

not saying it's right, not saying it's wrong. but if you treat a minor against the parents wishes... you'd better get a freakin' good lawyer. and even s/he may not be able to save you. don't forget that kids are not people in our game. their parents control EVERYTHING. i'm not speaking hypotheticaly here, i've been called to court and had to testify. whether it is right or wrong in your view has very little to do with the legal view. you cannot treat a minor against their parents wishes. i mean you can try, but the chick i was rotating with got a big ass black letter on her record for doing the medically "right" thing.

and now she's so scared that if anything controversial comes up, she's completely paralyzed... gotta talk to the ethics committee first... and first, they talk to their lawyers. and usually... and by usually i mean 99% of the time, you go with what the lawyers say... not with what medical sense.

don't ever forget that people have the right to refuse treatment. it might sound ******ed, but if someone says "no, i don't want this" you are MORALLY bound to say "okay."

this job is not easy - for a million different ways. but everyone dies, and sometimes, maybe it makes sense to let them choose their own terms.