45 yr old male, motorcyclist vs road. Primary survey - ABC all OK, GCS 15, nasty compound comminuted fracture R tib/fib, contaminated with bits of road and motorcycle, ischemic R foot that doesn't improve with leg manipulation. Leg manipulation does however cause bleeding. Secondary survey reveals only other injury is a pelvic fracture with a small amount of symphisis diastasis and a posterior sacro iliac disruption. Goes to OR for vascular exploration and repair of right leg, long procedure, lots of blood on the floor (despite intermittent tourniquet use), patient soon gets 15 u blood, 10 u platelets and is about to get his first lot of FFP for coagulopathy. (the amount of blood in looks about right for what is on the floor and I don't think the pelvis is the cause of the hypovolemia) Surgeons can't restore vascular integrity and are about to embark on a below knee amputation.
His family arrive and I go out to update them and they tell me he is a Jehovahs Witness! His fiance is JW as well and says he would not want blood under any circumstances and she doesn't want him to have anymore. The rest of his family are not JW and say they also think he would not want blood, but they would like us to continue transfusing as necessary. He has never signed an advanced directive, he was alert on arrival in hospital and at no stage prior to OR did he tell us of an objection to blood products. He is currently still asleep and about to arrive in ICU. His Hb is 75 g/l, platelet count 50, APTT 65, INR 2.2, the surgeons have had to leave the wound open and it is moderately oozy - they say the bleeding is not sugical bleeding ! He is still under resuscitated and probably won't be awake enough to extubate and ask him what he wants for another 4-6 hrs. My inclination is to continue to transfuse until I can ask him - given that he had time to tell us pre-op of any objections - and he didn't. This plan will not go down well with his fiance.
WHAT TO DO ?
John C. Mayberry:
Good example of an important dilemma which occurs frequently in different forms. A hospital lawyer would have to be involved at our facility and I would continue to transfuse as I think indicated until a team of surgeon, intensivist, hospital lawyer, ethics consult, etc. was able to convene and discuss the situation and give recommendations. I personally think we have very little responsiblity to a fiance.
David Crippen:
To me, it depends heavily on what you mean when you say "family". There is a pecking order in the realm of "family". For me, wife comes first, then kids, then mom and dad, THEN cousins, nephews and so on down the pedigree. Fiances get zilch from me as they are frequently interchangeable. So therefore, in the order of things, WHO sez he's a JW and who sez not?
This is very suspicious of manipulation. The family who are NOT Jehovah's Witnesses are more than likely to tell you anything that will cause you to do the right thing in their estimation. It seems to me that you are strongly implying that the PROXIMATE family, including the POSSLQ are giving you the straight dope.
Therefore, I think you are obligated to find the most proximate person in the pecking order and assume that this person is the official surrogate. Whatever that person sez goes.....that is unless you are willing to buck the well organized JW network who will shortly accumulate, if they haven't already, carrying reams of information about how patients with a hemoglobin of 0.0000005 g/DL can survive the big crunch.
The definition of a cult, as I understand it, is a propensity to dwell on superficial minutia at the expense of basic common sense. How much of this do you, as a physician faced with a life threatening situation, have to buy into? If you are willing to buck that system....and if you REALLY think the patient will die without a transfusion.............and if you are willing to die the death of 1000 ethics committee meetings.......and if you have a bucket of balls...........tell them all you're doing what you think the right thing is for your patient and they can sort it out after he's out of danger.
This is a risky proposition and this is an absolutely true story. My dad is a general surgeon and when I was a kid, I vividly recall a motor vehicle accident involving a minor child who came from a JW family. Family said no blood, the old man immediately petitioned the court for guardianship and it was granted in minutes. Operation was a success. Child did well. Family disowned the child, moved out of town and the child ended up in an orphanage.
Wow.......triple thickness, spot welded, atomic bomb proof suit on and leaving town shortly.......
Malcolm Fisher:
It is my understanding that in Jehovah's Witness patienyts the effects of blood transfusion in keeping you out of the 144,000 places in heaven are qualitative not quantitative and once you have had any your soul is stuffed. More will not alter that and stopping will not reverse it . the logical thing is therefore to continue transfusion.
Dick Burrows:
WHAT TO DO ?
You've already done it have you not.
As MF says it is not an issue that means Old Nick turns the heat up the more they get. It is an issue as to whether or not they get any in the first place.
Like many beliefs, cults, whatever they tend not to be consistent in terms of what affects their conscience and occasionally individual JWs may decide to allow some form of blood products or even blood.
As you have given blood (in the face of his implied refusal as garnered from relatives and his fiance) you will most likely be considered to have transgressed the ethical & legal rules. thus you may as well continue and be hung for a sheep as a lamb.
While I said that they were not necessarily consistent in their beliefs this bunch generally are more consistent but this is not so much due to the individual patient but their "support" group which will suddenly rock up with enough slanted literature to make you wonder or even convince you that The Big Man stuffed up when He gave us blood in the first place! As far as I'm concerned they are more interested in forcing home their principles of dogma than they are interested in the individual patient. In fact the patient is their means to their end.
I had a patient some years ago who bled to a haemoglobin of 1.3G% and as a consequence went into cardiac failure. If I could have dealt with the patient himself I could have come to some sort of satisfactory arrangement - even if it meant his death and that I was satisfied that he was prepared to martyr himself that way. But no, I had just about every JW in the country (legal & medical!) hounding me and trying to force my hand to act in the way they wanted - ventilation, inotropes etc. they even asked me if I knew what ventilation & inotropes were (they were a little distressed by my answer).
I got the impression that they simply wanted to prove their point of no blood - that the patient was a very secondary consideration. It was so bad that they planted an "Elder" to gently pump his wife under the pretext of lending succour. "Don't worry dear all will be well - but have they given the erythropoietin yet?"
He eventually gave consent for blood and got some then withdrew his consent again! But at least it got him out of the danger zone - got his Hb up to 5! They then insisted on transferring him out to another hospital where he would get treatment more in keeping with his beliefs. Funny thing happened though - without any transfusion his haemoglobin was measured a day later at 12.6 It improved paradoxically and spontaneously overnight! (I really must get my haemoglobinometers checked)
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.
John C. Mayberry:
Your choices are limited:
Ted Rogovein:
The card was found in the patient's purse by a nurse while looking for ID. If I recall correctly there was also something about the signature...either no signature or no witness or not dated...something like that...didn`t make any difference...Doc still lost the case....
David Crippen:
I am not at all sure that this suit would be considered authoritative or would make a viable precedent. I am equally not sure that the standard of care requires emergency physicians to sift through personal effects looking for reasons to avoid saving emergency patient's lives. This wouldn't be the first lawsuit that was won on other than merits of the case.
If the emergency physician used his best judgement at the time of an emergency situation, and he was genuinely not aware of the extenuating circumstances, I don't think he is liable for negligence. His/her first responsibility is to help the patient, not look for reasons not to.
I would be interested in hearing more about htis from legal eagles on the List if they are still around.
Giancarlo Rossi:
I Completyely agree with FL statement: there is a documentated hierarchy within parents (at least in Italy). First wife, then sons, then father or mother, then other relatives. I think fiance has not any power to decide for his life. If you REALLY think blood transfusion can save his life (or at least can give him one chance more) and if the closest relative agrees, you MUST continue transfusion.
Todd Dorman:
Several quick comments.
Leonard J. Soloniuk:
A devout JW would refuse EPG on these grounds, not wanting to get the concommitant albumin. This has been the stance of all the JWs to whom I have presented this issue. I have mentioned this to several surgeons, but that continue to administer it without informing the patient...
Stephen Streat:
As an aside I must tell you about a case I had many years ago as a registrar (1981) - he was 2 and was fished out of a swimming pool apneic, cold (23C) and bradycardic (AF, 20/min) with nasty aspiration. There was no history except - here is this poor child - please see and treat..
Amazingly he resuscitated after a lot of adrenaline and CPR etc and I gave him some red cells as his PCV was about 0.22 after resuscitation. THEN his parent were found and came in and saw the red cells and said "STOP - HE IS A JEHOVAHS WITNESS". I had quite a problem with this and suggested they speak with the Boss (the late Matthew Spence) who told them - this is true - in his best Glaswegian brawlers voice - "He looks like a bluudy pressbuterian to me". After a week of us all soothing VERY ruffled feathers (and three weeks of 100% oxygen) the child left ICU in good condition...
I agree with you - the patient had an opportunity to indicate his religion and or his wishes about blood productsand did not do this spontaneously. Question - was he specifically told about the likely need for transfusion ? If he was and said nothing then I would tell the fiance that the patient had made up his own mind pre-operatively and just exclude her from the loop. If he was not then I agree with you - unless someone can produce documentary evidence of his prior expressed wishes I would give him some platelets, vitamin K and plasma and fix his coagulation, red cells if his PCV got below about 0.2 and ask him about it in a few hours time...
Louis Brusco:
The physician lost the suit in that Canadian case because they found the card before transfusing but declined to adhere to the patient's wishes as stated on the card. The motto then is - don't go looking through the patient's belongings! For those who are interested, here are a few references I used when writing a recent review on this subject:
The canadian case listed above:
1. Malette v Shulman, 63 OR2d., 1987
2. Malette v Shulman, Supreme Court of Ontario, Court of Appeal, October 12-13, 1989.
Other papers that discuss the legal aspects of JW care:
3. Goldman EB, Oberman HA : Legal Aspects of transfusion of Jehovah's Witnesses. Transfus Med Rev 5:263-70, 1991.
4. Liang BA. Legal issues in transfusing a Jehovah's Witness patient following cesarean section. J Clin Anesth 1995; 7: 522-4.
5. Sugarman J, Churchill LR, Moore JK, Waugh RA. Medical, ethical and legal issues regarding thrombolytic therapy in the Jehovah's Witness. Am J Cardiol 1991; 68: 1525-9.
6. Sacks DA, Koppes RH. Caring for the female Jehovah's Witness : balancing medicine, ethics and the First Amendment. Am J Obstet Gynecol 1994; 170: 452-5.
Lou Brusco:
If he did not say anything, AND he does not have a card on him saying that he is a Jehovah's Witness and he would not want blood even if he died, AND his family (who are the legal guardians of him with him unconscious) are "not sure", then you go ahead and give him the blood products. Even if the family were adamant that he NOT get blood, I would consult the hospital lawyer for the legal precedents in New Zealand. You may cause his fiance to leave him, but that is a small price to pay.
David Crippen:
We're slicing and dicing with words here, Lou. Lets pull on the fireproof suits here and get down to the real issue.
A much bigger question is simply how willing you are to buck a lethal quibbling over biblical semantics to allow your patient another chance at interpreting scriptures in a more pragmatic fashion the second time around. A lot of religions have habits and practices that seem odd to the mainstream.....Catholics (used to) eat fish on Friday, Jews don't eat pork because in antiquity pork was universally infected with worms and it was probably a good thing they didn't. But it is now the 20th century and there aren't any more worms in pork but they still don't eat it. So what. Avoiding pork in 1996 doesn't kill people so who cares.
Avoidance of blood products in antiquity was probably a hygienic thing as well but getting a life saving transfusion isn't the same as eating infected blutworst. This odd interpretation of one sentence in the bible, meant for a radically different situation kills people. So I ask again, given that the basis for this prohibition has no validity in any other than folklore, how much should I have to buy into it as a trauma surgeon? If a patient looks me in the eye and tells me he would rather die than get blood, and I think that decision is authoritative, I am obliged to back off. Period. When that same patient is incapacitated and unable to tell me his/her "true" wishes, I am not so sure how interested I am in giving ANY credence to ANY surrogates. I might be real interested in bucking the system if it comes down to "real" life or death, which it rarely does.
Lets put each other on the spot with a hypothetical:
Adult trauma victim, Shot several times by a demented rapper depressed over the demise of Tupac. Bleeding from abdominal hemorrhage BIG TIME. You are a trauma surgeon (yes...I know, take some benadryl and it'll get better). The patient has no family physician and YOU are the physician of record. The family rushes in just as the patient is wheeling into the OR and loudly announces that he is a JW, he does not want any blood on pain of death and they don't want him to have any either. Not one but two fiances arrive later and each reiterate the same story....eyeing each other suspiciously patient's belly is open, blood is pouring from everywhere but you are in luck.....standing across the table from you is the world famous "hands from God", Dr. Ken Mattox. You already know that this guy has a shot at it. But it's going to take some time and you are in DEEP blood trouble here. The anesthesiologist tells you the hemoglobin doesn't register on the spun down capillariy tube. The blood coming out of the liver looks like dilute Koolaid. The patient is wildly tachycardic even though the anesthesiologist is pumping Hespan and saline through three big bore lines through a Level-One gangbanger.
Dr. Mattox looks across the table at you and curses softly........"Shieeeeet, we bettah get this guy some heme pretty quick or he's gonna chomp the big one right here in front of God and everyone". The anesthesiologist nervously fingers several units of type-specific blood. The patient is CLEARLY circling the drain (Clockwise........you are in the Northern hemisphere).
You are in charge........what are YOU going to do about this INDIVIDUAL, Doctor?
Thomas Stinson:
Although I have (thank God) never been faced with an exsanguinating putative (but not certain) JW patient, the only circumstances under which I would let a patient die for lack of blood would be that in which the patient, while fully conscious and cognizant, had told me that he would want to be allowed to die rather than receive blood, or where I had been presented a Massachusetts statute-compliant Health Care Proxy naming a proxy who then told me that the patient would prefer to die rather than to receive blood. In the latter case, however, I would feel very uneasy about so doing.
I fully respect the religous opinions of JW's (and others) and have no qualms about their prefering martydom (in their view) to apostasy, but I want to have (at least) "clear and convincing" evidence that this is, in fact, their wish. Since Massachusetts law has provided a specific, legally binding form for a person to use in issuing directives about his health care after he has been rendered incapable of expressing his desires, I feel justified in ignoring expressions of his wishes that fall short of this standard, such as verbal assurances, directives, threats etc from relatives. Furthermore, in an emergency (which this certainly is) common law generally grants the caregiver consent to do all necessary to save the life and health of the uncommunicative patient.
Thus, in the case presented by Dr. Crippen, I would not hesitate to transfuse. Of course, I would try to document the entire event, including my reasoning in the chart, and would not be surprised if the patient or, more likely, his family (if he did not survive despite the transfusions) sued; however, I think it fairly unlikely (the Ontario case notwithstanding) that I would loose such a suit. On the other hand, in a case in which I am personally certain that the patient would refuse transfusion (because I had asked him/her so in very specific terms, without the presence of any relatives, JW elders, etc preoperatively), I think that I could let him/her die for lack of transfusion with a clear conscience.
Aviel Roy-Shapira:
If he did not say anything, AND he does not have a card on him saying that he is a Jehovah's Witness and he would not want blood even if he died, AND his family (who are the legal guardians of him with him unconscious) are "not sure", then you go ahead and give him the blood products.
What does the family have to do with this? As far as I know, members of the patients family are NOT, ipsi facto, the legal guardians of any unconcious adult. The next of kin may be the most likely candidate for appointment as one, but until the court appoints a leigal guardian (by a rather tedious process, in all countries governed by variants of the Common Law) no one has that authoritiy.
The family is ususally the best source of information about the victim wishes. That is all the authority they legally have. !. In that regard, the fiancee may be a better source than the parents, in that she may know better than they about his wishes.
Nevertheless, here there is a better authority about the patients wishes than even the fiancee, and that is the patient himself. Therefore, any delay in trasfusion is unjustified, and can be acted upon in Court.
The reason why legal guardians are always appointed by the courts, is that they have to convince the court that they will act in the patient's best interests. One can easily imagine a scenario where the interests of the family and of the patient do not coincide. There may be conflicts with inheritence, wills, and not wishing to burden the estate with a huge medical bill, for example.
Louis Brusco:
I have the benefit of having had to think this over very carefully in the course of writing my review article. My feelings on the subject are:
In your hypothetical case, yes, I would give the blood.
Reminds me of a case I had of a JW who was GI bleeding and unconscious - she had signed our JW consent. Her "brothers" and "sisters" came by to make sure that we were adhering to her wishes. Just before she was beyond the point of no return, one of my clinic patients came by, and told me that the patient was her next-door neighbor, and that the people who had told us that they were her "brothers and sisters" were, in reality, fellow members of the congregation. We were then able to contact her real sister, who was not a JW. We were able to lighten up on her sedation to get her to give us permission in fromt of the sister to accept the transfusion. She lived, and the other "brothers and sisters" never came by again.
David Crippen:
When you take on the responsibility of an acute care physician, you get to make tough decisions, sometimes ripping up unplowed ground in the process. No one ever said there's a road map to any of this territory. Like Gordo the Doig sez...when you're having sex with a gorilla, you don't quit when you're done, you quit when the gorilla's done.
Allowing preventable death at the behest of secondary information sources obviates the possibility of the patient "changing their mind" in the clutches of life threatening reality. Ordinarily devout people change their minds all the time. The family has no way of knowing whether or not the patient would rather take a chance on explaining these extenuating circumstances to his God at the Pearly Gates at a much later date.
Most legitimate religions allow for extenuating and mitigating circumstances to provide safety valves for ritualized behavior. One that doesn't has to have safety valves added by outsiders sometimes. Maybe that takes the responsibility off them in the end. In my hypothetical case, I would give the blood in a heartbeat.
Wrapup: Tony Smith:
Thank you all for your replies.
He continued to bleed for a while and I continued to transfuse him. He gradually woke up and was extubated and I shooed everybody (including the JW elders who had turned up) out of the room and spoke at length with the patient. He grabbed my hand and thanked me so profusely that I had to prise his hands open to get mine out, he went on to say that he would be happy to continue to recieve blood products. He stopped bleeding with platelets and FFP and went to a ward, the surgeons are planning a long and bloody pelvic fix.