Specific interview question: how'd you answer it?

[Bruin4Life]

I cut and paste the following question from the new feature on SDN interview feedback. It was asked at the university of Utah according to the poster.

"Woman getting a Cesarian and her platelets are low. Of course, her religion calls for no infusion of blood products. She says no blood products. She passes out. She is in a bad way. Her husband says "give her blood." What do you do?"

Personally I think this is a tough question, maybe because I haven't taken an ethics class. Anyway, as far as I know the courts do uphold a Jehovah Witness's decision to refuse blood infusions. If the husband was not there to voice his desire, I would not infuse blood and would do everything possible to stabalize the patient, including any other medication or procedure that would help the case. However, in this case, I think family members know and want nothing but the best for the patient and thus I would have to consider her husband's wishes. Since the wife was physically very sick,I would argue that the patient's husband might have been more competent to make a more wise decision on her behalf.

How would you guys address this question?

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[THE instiGATOR]

Unless this is an emergency, you are screwed anyway. The platelet count should have been done before the Cesarian.

Also, all the Jehovah's I know would NEVER marry outside of their religion. I think this is silly, but it seems to be the norm.

I think the liklihood of this scenario is rather slim. Any way you slice it, though, I think you are obligated to let the woman die if no alternate treatment is working. I don't know the law, however. I may be wrong. It would be a tough call.

 

[Premed315U]

Does anyone have other tough but interesting interview questions they encountered?

 

[racergirl]

I'd give her the blood or whatever. I'm sure God wouldn't mind, but if s/he did he could blame me. Plus, you got hubby right there consenting...

 

[LizardKing]

This is a no-brainer. There are multiple laws that protect doctors in such situations. Especially if the lady is unconscious and about to die. Unless she presents a Do Not Resuscitate Order or something to that extent, there is implied consent because she is not in the right mind (i.e. unconscious) to make decisions about her own treatment.

Let's say, for the sake of discussion, she was conscious. In a life-threatening situation, unless, again, she has a court order right in front of the doctor, she cannot refuse treatment...If she does, she is classified as a danger to herself and can actually be arrested for it!

Basically, if a patient is dying and sets foot on hospital grounds, the doctors treating her face no dilemmas because it is their duty and obligation, legally and ethically, to save her. Doing otherwise is tantamount to negligence.

 

[Milena]

I agree- that's a great response, I think. However, if the patient didn't have a husband or family member present, and had made it clear before the illness that she didn't want a transfusion (I think they carry cards in their wallets) I would not transfuse, regardless of a physician's aim to protect life.

 

[THE instiGATOR]

I would hate to see her die, but it is her wish. I'm certain that her faith would have been brought up before the Cesarian. She must have been fully coherent, unless this is an emergency. Having talked with many Jehovah's, I know that they are serious when they say they don't want blood. You won't be doing any favors by disregarding her beliefs.

 

[alice]

Just to add fuel to the fire:

Why is it acceptable and necessary for doctors to let these people kill themselves by refusing treatment and so many times illegal for them to assist in suicide?

In our separated-from-church state, it seems inconsistent that one moral standard should be upheld at the expense of life and another circumvented at the expense of final rest.

For the record: I am not sure I am even pro-euthanasia, but I find this an interesting legal paradox.

 

[tidy_kiwi]

You could be really smart and say that by the time you graduate and are potentially exposed to this situation then you could order an infusion of some kind of synthetic haemoglobin/perfluorocarbon suspension and there would be no prob - assuming that these have been fine tuned by then. Otherwise I'd probably have to go ahead and give the blood, unless the patient had signed some kind of DNR thingy.

 

[Yogi Bear]

accept_me,

so did u get in to utah?

 

[Ranger Bob]

Unless there was evidence that the patient was incapable of making an informed decision about her care, I would respect her wishes and not give her the platelets. Patients have the right to refuse treatment, even if their reason for refusing treatment appears irrational.

I find it interesting that nearly everyone has responded to the hypothetical dilema by wishing it away (denial!). In the given situation, the woman WAS conscious and by all indications WAS mentally and physically capable of refusing the treatment. You can't ignore her wishes just because you find it easier to agree with the husband.

 

[BlackPuma]

lets see isnt this obvious...

if the patient, SIGNED something saying, Don't you dare transfer blood...then the hospital is liable NO MATTER WHAT THE HUSBAND SAYS...

on the other hand, if the there was only an ORAL contract, nothing on the books, and the husband begs and pleads with you....the hospital can make a form, making the HUSBAND LIABLE FOR ANY damages or any reason that the wife might get upset/angered after the treatment...and then she can sue his sorry A$$

pple pple pple...all you need are WRITTEN CONTRACTS....its not a matter of he said or she said...if she told me she didnt want blood transfusions, and she was not at a Mental state that realized the gravitiy of the situation then you can't take a word she said in passing....however, if she said SIGNED something going to into surgery/treatment....then the hospital is liable, so I personally WOULDNT GIVE HER THE BLOOD....it's her death wish...sorry

 

[Ranger Bob]

Accept_Me: Thanks for the clarification. It sounds like the question, and answer, were not as obvious as I understood from the original post. When answering ethical questions, I think the key is to show that you understand the key issues -- not that you answer the question one way or another. I'm sure you did a good job on the question.

WatchaMaCallit: Of course, if we have a bunch of signed affadavits, we can dodge many thorny ethical issues. But I think that interviewers want us to face those issues head on, not dodge them. Also, I suspect that in the real world, there's rarely time to have everyone sign a legal document. DNR orders and the like are the exception, not the rule.

 

[LizardKing]

Who's actually in denial? You do not let a person die based on word of mouth. The lady has presented no legal papers prohibiting doctors from giving her a transfusion. If she did present such papers (implying she fought quite a bit legally to get them and would not hesitate turning a case on you), of course you can't break the law, case closed.

Without those papers, though, the lady has no right to command what you should and shouldn't do. It is a life-threatening situation, and frankly put, you can't withhold treatment just because a procedure is going to make a patient feel uncomfortable, no matter how uncomfortable it may be. You don't ask when a patient's lungs are filling with blood if it's okay to put in a chest tube...sure, you should tell them nicely, but when it comes down to it, no matter how combative or anxious the patient is, you have to do what you have to do to save them. Trust me, if you don't act to give them blood, somebody else on the staff will understand the situation and step in for you.

Let's say there are synthetic blood alternatives immediately on hand...that would be great. In reality, these may or may not be available in time, and, in most cases, by the time you could get a hold of enough, the patient would die or their treatment seriously compromised.

 

[LizardKing]

In the real world, everything does boil down to legality and paperwork in the hospital. There are a lot of situations in the ER, for example, that are iffy like this one. Without doctors worrying and seeking legal papers and proof all the time, as well as copious records being taken about patients, it would be a free-for-all! I've stayed in the hospital before for both minor and major health problems, and believe me, I had to sign a sh*tload of papers for the most innocuous things!

•WatchaMaCallit: Of course, if we have a bunch of signed affadavits, we can dodge many thorny ethical issues. But I think that interviewers want us to face those issues head on, not dodge them. Also, I suspect that in the real world, there's rarely time to have everyone sign a legal document. DNR orders and the like are the exception, not the rule.•••

 

[BlackPuma]

Originally posted by Ranger Bob:
•Accept_Me: Thanks for the clarification. It sounds like the question, and answer, were not as obvious as I understood from the original post. When answering ethical questions, I think the key is to show that you understand the key issues -- not that you answer the question one way or another. I'm sure you did a good job on the question.

WatchaMaCallit: Of course, if we have a bunch of signed affadavits, we can dodge many thorny ethical issues. But I think that interviewers want us to face those issues head on, not dodge them. Also, I suspect that in the real world, there's rarely time to have everyone sign a legal document. DNR orders and the like are the exception, not the rule.•••

actually, I think hospitals do require patienst to sign documents...when I went to pull my wisedom teeth, my dentist made me sign a contract that if for any reason, I had pain, discomfort, droopiness of my face, or even death, that he was not liable in any way shape or form and this was for a wisedome teeth...ain't that nice?

 

[none]

So do most hospitals have a notary public standing around in the ER ready to draw up responsibility contracts? I guess I didn't notice the one in the ER I was working in...

 

[Ranger Bob]

LizardKing: You seem to be assuming that a patient must present you with legal documents in order to avoid having an unwanted treatment forced upon them. That assumption is utterly false. Patients have the right to refuse treatment. You do not have the right to force treatment on an unwilling patient. The only tricky question is whether the patient is capable of making decisions about their own care.

Everyone: I find it disturbing that many of my future colleagues are so eager to abdicate their ethical responsibilities to attorneys. Yes, we are obliged to follow the law. Yes, we feel compelled to cover our legal asses. But in the real world, there is rarely the time or the money to involve attorneys in most ethical issues, and it is necessary for physicians to employ ethical reasoning without legal counsel.

 

[Ranger Bob]

There is standard paperwork for many standard procedures. Usually, the paperwork has to do with informed consent. The patient signs to show that he or she understands the risks associated with a particular procedure. The patient's signature covers the hospital's and doctor's legal asses to a limited degree. This is a good thing. But it has little to do with the ethical question posed at the start of the thread, for a few reasons:

1) In emergent situations like this one, the clinical situation may require a decision before there's time to sign any legal paperwork.

2) It is unlikely that any of the standard legal documents would fit this rather unique situation.

3) Most informed consent paperwork has to be signed in order for the patient to ACCEPT treatment. (DNR is one of the few counterexamples.) In this case, LizardKing (and others) want to do just the opposite: make the patient present paperwork in order to REFUSE treatment.

4) When an interviewer asks an ethical question, he doesn't want you to say, "I'd call the legal department and do what they say" -- even if that's exactly what you would do in a real situation. He wants you to demonstrate that you understand some of the basic ethical principles of medicine (in this case, the patient's right to refuse treatment when capable of doing so).

 

[LizardKing]

No, Ranger Bob, that's not what I am assuming. I'm talking about cases where the patient is about to die unless a specific procedure is to be administered. Sure, patients have the right to refuse treatment, but they don't in the case where they are about to die. Even paramedics, I know from experience, can treat and transport a patient using police force, if necessary, if a patient refuses treatment even though he is dying. Quite simply, the rules change when it's life-or-death, and a patient must present DNR or a valid form to refuse treatment in such a situation. It may not be a warm and fuzzy solution, but neither is medicine. I also believe that this legality, in which a patient must present valid documents to avoid life-saving treatment, is the intelligent and ethical solution. Anyway, all legal issues aside, you're telling me you have the stomach to sit and watch this lady bleed to death right in front of you? Even though you have a simple fix to save her life? I think it's a duty and part of the Hippocratic oath to save a patient--we're not talking about performing some routine procedure to make her feel better--if you have the means.

Originally posted by Ranger Bob:
[QB]LizardKing: You seem to be assuming that a patient must present you with legal documents in order to avoid having an unwanted treatment forced upon them. That assumption is utterly false. Patients have the right to refuse treatment. You do not have the right to force treatment on an unwilling patient. The only tricky question is whether the patient is capable of making decisions about their own care.

 

[WildChild]

In reply to LizardKing:

Just for your info(and in case this situation ever arises in one of our futures), the situation is not a no-brainer. Patients do have the right to refuse treatment. The law varies state from state, but if the will of the patient is clear, than doctors must follow their wishes. See the case In re A.C. for more info.

 

[LizardKing]

Actually it is a no-brainer because patients don't have the legal right to refuse treatment if it's a life-or-death situation (unless they have the paperwork). That's how EMTs and paramedics are able to arrest individuals under a certain code if they are bleeding to death and refuse to cooperate. That's what also gives doctors leverage to strap combative yet dying patients down if they are trying to escape...Legally, if one is a threat to oneself, whether suicidal or, in this case, refusing life-saving treatment, it is actually a crime and you give up certain rights.

Originally posted by lrmodrich:
•In reply to LizardKing:

Just for your info(and in case this situation ever arises in one of our futures), the situation is not a no-brainer. Patients do have the right to refuse treatment. The law varies state from state, but if the will of the patient is clear, than doctors must follow their wishes. See the case In re A.C. for more info.•••

 

[Ranger Bob]

The right to refuse treatment does not depend on the seriousness of the patient's condition. It depends solely on the patient's mental and physical ability to refuse treatment.

The DNR order applies to a fundamentally different situation than the one posed at the beginning of this thread. The DNR order takes effect at a time when the patient is unable to express his or her wishes. In the original post, the patient was perfectly capable of expressing her wishes.

 

[LizardKing]

Hey Ranger Bob, I looked this stuff up in several journals, and came to the conclusion that this stuff is murkier than any of us realize...so you're right, it's not a no-brainer and I was wrong about that. There are conflicting legal issues here. Some laws state that a person, if a danger to himself or herself, can be forced to accept treatment. However, there are courts that have argued plainly that patient rights come first: "That court [New York Court of Appeals] has also observed that "the ethical integrity of the medical profession, while important, cannot outweigh the fundamental individual rights here asserted. It is the needs and desires of the individual, not the requirements of the institution, that are paramount."

So I'm beginning to agree with you, but not wholeheartedly because there are conflicting laws and of course ethical concerns. Anyway thanks for enlightening me, Ranger dude.

 

[Ranger Bob]

LizardKing: Where did you find those quotes? I think it would make for interesting reading, and I'd like to have a handy legal reference at my disposal for future use.

 

[LizardKing]

The reference is BLOOD: WHOSE CHOICE AND WHOSE CONSCIENCE? by J. Lowell Dixon, M.D. (from the New York State Journal of Medicine, 1988; 88:463-464, copyright by the Medical Society of the State of New York.)

Find it here:
<a href="http://www.watchtower.org/library/hb/article_07.htm" target="_blank">http://www.watchtower.org/library/hb/article_07.htm</a>

 

[LizardKing]

I think this issue brings in some issues about treating combative patients and about euthanasia. I mean, I find it odd that the hospital staff can basically pin down, sedate, and even intubate a patient who downright refuses treatment (he/she might be on PCP at the time or have gunshot wounds or can be in the right mind but hates the hospital, etc.) but has no religious reasons to do so. In contrast, a person, because she claims religious reasons, is not only to be believed but also granted her wish to die in the hospital? Where do we draw the line between these two extremes? How about patients that simply want to die but have no court order, no religious reasons, and are simply in great pain...in cases like these, what separates a doctor intentionally injecting KCl to kill the patient as the patient wished versus a doctor who decides not to give needed blood, killing the patient? I mean, of course, one is actual killing and the other is withholding something life-saving, but the result is the same--a dead patient due to a doctor's choice. I'm sure none of us would want this type of death on our conscience, let alone sit there while this was going on and do nothing. I think I'd rather face the legal repercussions than knowingly let someone die.

 

[LizardKing]

Hey it turns out there was an identical case to the one mentioned in the original post. The court ruled that another court should not have given an emergency worker the right to give her blood even though her husband consented. Check this out:
<a href="http://subscript.bna.com/SAMPLES/hce.nsf/85256346006d1c0885256113002144e4/bf12acde47cb860b85256a03000565eb?OpenDocument" target="_blank">http://subscript.bna.com/SAMPLES/hce.nsf/85256346006d1c0885256113002144e4/bf12acde47cb860b85256a03000565eb?OpenDocument</a>

 

[THE instiGATOR]

Originally posted by LizardKing:
•...but the result is the same--a dead patient due to a doctor's choice.•••

Nope, we're dealing with the patient's choice here.

Do you not see something wrong with one person forcing blood into the body of another without consent?

 

[LizardKing]

On the flip side, don't you think something is inherently wrong with letting someone basically commit suicide in front of you? I don't think either side is completely ethical...But weighing them both against each other, all legal issues aside, letting a patient die is more abhorrent to the medical profession and to the patient herself than that one patient's concern. Like I said before, not everything doctors do in trauma and emergency situations is under full consent (i.e. pinning and sedating combative patients down who are trying to escape and who may still be fully aware of things). I think in totality, the moral decision is to save a patient no matter what the cost, provided the patient will not become a vegetable. Why? Because that decision--to provide life-saving care--outweighs the doctor's responsibility to accomodate all of the patient's wishes. From the hippocratic oath to all of the other pledges doctors ascribe to, that decision takes precedence over other duties. Granted, this may curb individual rights, etc. But certain things about the profession must be upheld. Of course the courts may disagree, but I'm talking big picture, without all the legal restraints and b.s. that cloud the whole perspective.

Originally posted by SwampMan:
•

Nope, we're dealing with the patient's choice here.

Do you not see something wrong with one person forcing blood into the body of another without consent?•••

 

[LizardKing]

How about the situation with a minor who has a guardian who is a Jehovah witness? Let's say the kid was taught that it was wrong to accept blood, and here he is dying. He says he is against receiving blood...who knows if he can even make that decision though. His guardians are also against him receiving blood. So you let this kid die the same?

 

[BlackPuma]

Everyone: I find it disturbing that many of my future colleagues are so eager to abdicate their ethical responsibilities to attorneys. Yes, we are obliged to follow the law. Yes, we feel compelled to cover our legal asses. But in the real world, there is rarely the time or the money to involve attorneys in most ethical issues, and it is necessary for physicians to employ ethical reasoning without legal counsel.[/QB]••

ummm yah, with that kind of attitude, that is how a hospital gets a 12 million lawsuit up their b*tt

 

[UCMonkey]

I just read this thread, so let me comment on some of the things I've read:

We talked about this type of situation at a workshop with an adcom member. What I think it boils down to is this: A patient who is mentally competent has refused treatment. THEN the patient becomes metally incompetent (loses consciousness). What we were told by the doc was that in these cases, paperwork or not, the patient's wishes stand. That's my personal position.

The "implied consent" argument in this case sends us down a slippery slope: General anesthesia puts people unconscious. Does that mean that once someone is out, we can ignore their stated wishes before they were put under?

Also, as far as I know, just because platelets are "low" (how low?) does NOT mean that the patient will die. Yes, she will probably lose some blood, but if the bleeding can be reasonably controlled via cautery and good surgical technique, and IV fluids given to maintain volume, the patient probably has a decent likelihood of surviving.

Also, with regard to restraint of trauma patients: People who are totally with it are generally not combative. Even though they may be aware of their surroundings, their behavior may be indicative of a head injury, which can affect competence. These people are also a danger to others, most notably everyone else in the ER.

Finally, in response to LizardKing's post about paramedics: That's a major leap to make from paramedic to MD. I know that (in CA at least), unless presented with a DNR order, paramedics are required to resuscitate dying patient. Also, every situation I've ever seen where paramedics have needed police help either involved someone in custody or someone who was pretty combative, (refer to my above thought on combative patients). Outside of this, though, patients CAN AND DO refuse paramedic care, and the medics carry AMA (against medical advice) forms for the patients to sign.

Bottom line: Medical personnel by law cannot force unwanted treatment on a mentally competent patient. We cannot prevent people from making what we believe to be bad decisions about their health, even if the end result may be their death.

There, I've said my piece.

 

[LizardKing]

Well said, Monkeyrunner. Toward the end of my statements, I've just been saying how even though the law states that doctors can't force treatment upon an individual, I don't think it's necessarily the way things ought to be. This dilemma does not have to boil down to a transfusion...it can be the refusal of life-saving treatment altogether. Where exactly do you draw the line between suicide and this form of capitulation?

 

[UCMonkey]

A good point LizardKing. Here's my take on suicide vs. capitulation. What we have here si a question of intent. Suicide is intentional. A suicidal person WANTS to die (or at least thinks they want to at the time they take action), for whatever reason. Wanting to die is not a normal frame of mind, therefore the person is mentally incompetent.

In our case study here, the woman went to the hospital, and agreed to the c-section. I think we can reasonably infer from this that she does not want to die. I think that we can take from this that she does not have suicidal ideation. That said, being of sound mind then, she has the right to refuse whatever she wants to refuse. If she said the voices in her head were telling her no blood products, we'd have a different situation, but that is not the case.

Also, ideally, before the procedure she should be allowed to sign something refusing blood products, perhaps like an abbreviated AMA, acknowledging that she has been informed of the risks of her refusal. Unfortunately that is many times just not practical if there is to be a chance of saving her life and/or the baby's life.

Again, bottom line: Suicidal people have have suicidal ideation: they WANT to die. This makes them a danger to themself and therefore incompetent. People who do not WANT to die (which can be determined either my the attending or a psych consult if there's time) still have the right to refuse whatever they want to refuse, as in our case here.

 

[jdub]

btw,

dnr's are not that clear cut either. a kid could have a dnr and if they aren't 18, a parent could revoke it, or their signature that was on it.

also, if a husband or another family member who was in the hospital with a dnr decides that they don't want to let their loved one pass, they could also cause a huge fit and probably get a dnr revoked.

 

[UCMonkey]

Good point jdub. The rule I was taught was that if any relative says resuscitate, then you resuscitate. I guess the theory is that dead is dead, but you can always reinstate the DNR later if the resuscitation is successful.