A Dilemma of Blood Transfusion

Lindsay Bussard

Chris Cummings

Jaclyn Nicholson

The Case

• A 28 year old woman, Sarah, spends a day hiking/climbing with her boyfriend, Justin.

The Case• Sarah falls

during the hike and suffers multiple injuries including a large laceration her right thigh.

• She is airlifted by search and rescue to a local hospital

The Case

• Justin is able to inform the medical crew that Sarah has ITP.

• ITP explains her profuse bleeding.

The Case

• Sarah’s vital signs are unstable at ER• Unconscious • The medical team believes she will need a transfusion

The Case

Sarah’s mother, Janet, informs the team Sarah is Jehovah’s Witness and would not want the transfusion, but Justin pleads for the transfusion to be given.

Ethical Questions

Should the medical team honor Sarah’s supposed religious wishes even if it means her life will be lost?

Should the team regard Janet’s thought’s about her daughter’s wishes as absolute?

Ethical Questions

Should Justin, as Sarah’s boyfriend, have a say in her care?

Should the team give Sarah what they believe is the best possible treatment?

Ethical Questions

How does the team decide what Sarah would truly want without her input?

Step 2: Gut Reaction

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

The gut reaction is to save this young woman’s life.

Step 3: What are the clinically relevant facts?

The Bible states in various places that people should not eat blood. Jehovah’s Witnesses interpret this to mean that they are not to take blood into their body in any manner, including transfusion.

Step 3: What are the clinically relevant facts?

Sarah does not have a living will. She is also not carrying a signed card with her stating that she would refuse a blood transfusion in an emergency.

Step 3: What are the clinically relevant facts?

Several court cases have set the precedent that a conscious, competent individual can refuse a blood transfusion, even if doing so will cause their life to be in danger.

Step 3: What facts do you need to gather?

Does Janet or Justin have a signed document stating Sarah’s wishes?

Does the medical team know Sarah and have previous knowledge of her stance on blood transfusions?

Is Sarah pregnant? In this case she may be forced to receive a transfusion against her wishes.

Step 4: What are the values at stake for all the relevant parties?

Sarah: Life and Autonomy

Janet: Eternal Life and Autonomy

Justin: Life and Non-maleficence

Medical Team: Respect for patient’s rights and Beneficence

Step 5: What could you do?

• Give the transfusion.• Try an alternative treatment.

• Do nothing.

Step 6: What should you do?

Give the transfusion to save her life.

Step 7: Justify Your Choice

•We want to respect Sarah’s wishes, but she is unable to tell them to us.•Justin and Janet cannot agree as to what the proper treatment is for Sarah.•As healthcare providers, we decided to err on the side of life.

Decision to Transfuse

•We therefore decided to give Sarah a blood transfusion.•Once she is stable, we will strive to obtain her personal wishes and advocate for them during the rest of her treatment.

Values to Uphold

•Performing the transfusion, we are promoting beneficence and non-maleficence, while seeking to restore Sarah’s autonomy upon recovery. We as providers have a respect for Sarah’s life, but also want to maintain and respect Sarah’s rights and integrity.

Codes of Ethics

Our codes of ethics drive us as providers in the right direction. Sarah is our patient, and as nurse, physician assistant, and doctor, we value our patient first and foremost and act as advocates for her. The best interest of Sarah is to stabilize her such that she can state her wishes so that they can be promoted from there.

Possible Counterargument

Sarah is an adult, and if her mother states she is a Jehovah ’s Witness, those wishes need to be respected. After all, if Sarah’s had ITP for some time, and has yet to receive blood to treat it, is it really that difficult to think that she would not want blood now either?

Response

Sarah has never been put into a life-or-death situation before, and as such, we cannot determine what her wishes are, as they may change given her imminent health status. We as providers have Sarah’s best interest in mind, and her best interest right now is to do everything possible to continue to live.

Step 8: How could this ethical issue have been prevented?

Sarah could have avoided this situation, as anyone can avoid such a situation, via a power of attorney or a living will. These documents would have appointed a sole person as her proxy decision-maker, or described her wishes regarding specific medical treatments in various healthcare situations.

References

• The Bible, New International Reader’s Version• Cases –

• www.watchtower.org Official JW Site• Anesthesiology News, October 1989.• Watchtower magazine, June 15, 2004.• Management of the severly anemic patient who

refuses transfusion: Lessons learned during the care of a Jehovah’s Witness. Mann et. al., Annals of Internal Medicine. v 117, n12. 15 Dec 1992.

• www.cobar.org Information on Advanced Medical Directives

Norwood Hosp. v. Munoz 409 Mass. 116; 564 N.E.2d 1017 (1991)In re Estate of Brooks, 32 Ill. 2d 361, 205 N.E.2d 435 (1987)