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Tricky MMI question?


Poloma

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"You are on duty in the ER when an unconscious three–year-old girl is brought in. It‟s clear that she needs an immediate blood transfusion to survive, but her Jehovah‟s Witness parents are adamantly against it. What would you do and why?"

For me, the answer to this seems obvious: 

- Inform parents of options/urgency of situation 
- Mention autonomy vs. beneficence 
- Highlight cultural mosaic in Canada & importance of respecting religious beliefs 
- If parents adamant, consult hospital ethicist/ethics board and see if you can get legal permission to still do transfusion 
etc. 

But what about in a case where you don't have time to contact an ethicist or get a hold of someone? Is it ever ok to act on your own as a physician to make a decision that overrides autonomy when the individuals are sound of mind?

Thanks! P

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This topic has been brought to the supreme court before. I think the bottom line is that if you can delay then you involve ethics and other parties, and if if it is a true emergency then there are some protections that allow you to act to save their life against the wishes of the parent. This is what the canadian pediatric society says about it (https://www.cps.ca/en/documents/position/medical-decision-making-in-paediatrics-infancy-to-adolescence):

"Occasionally, serious disagreements over what constitutes the patient’s best interests persist among equally appropriate SDMs or between SDMs and HCPs, even after a collaborative decision-making process is implemented. Some examples include disagreements between parents with joint custody, the wish of HCPs for life-saving transfusion of blood products for a child whose parents refuse based on cultural or religious beliefs [32] or, conversely, the desire of parents or guardians to continue life-sustaining interventions when there is little hope of reasonable recovery. In such cases and if circumstances permit, the proposed intervention should be delayed while an attempt at resolution is made in the current clinical setting [23]. This step may involve further discussions and/or referral for a second, independent medical opinion.

Consulting with a spiritual care leader, social worker, patient relations expert, bioethicist or a bioethics committee, or with institutional or personal legal counsel, is often a useful step in complex cases. If the young patient’s life is at risk, child welfare or child protection legislation mandates reporting in most jurisdictions. In such cases, consent will be given or withheld by a court. In the event of a true emergency, where time does not permit an HCP to access the options described, the ethical principles of beneficence and nonmaleficence, as well as laws under the emergency doctrine, permit the provision of emergent life-sustaining interventions."

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Even if it is an emergency, it takes some time to get blood up from the blood bank. Often it can take an hour to crossmatch the blood and bring it up...and even if you are in a trauma situation it can take several minutes to get generic O- blood up from the blood bank, so you would probably at least have time to get someone to look up the rules for you while you are seeing the patient, or to talk to another doctor to decide together about what is the most reasonable course of action etc. If you were challenged in court, it would probably be helpful if you had sought advice if you had a little extra time. You could also speak to hematology/transfusion medicine/blood bank etc about alternatives. 

It sounds like overall you are aware of the issues of the dilemma, which is the important part of these ethical situations.

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Throwing in my 2 cents here.

Because the kid is 3 years old, you have a right as a physician to perform life saving treatment. The main issue here is that the child is too young to make a decision for herself, i.e. she is incapable. It's important to discuss this with the family, and discuss the importance of honouring cultural beliefs wherever possible, but in this case, the only really acceptable course of action is to treat the child.

According to UWash bioethics (this is a similar case about bacterial meningitis):

"The physician has a duty to challenge the decision of parents when their refusal of treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his or her view with the family and seek to elicit their cooperation through respectful discussion... Should these efforts not result in parental permission, the physician is justified in seeking legal authority (in the form of a court order of authorization from a state child protection agency) to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm." (This was from a US example, but I believe similar rules apply in Canada)

On the other hand, if the child was older, e.g. 15, and deemed capable of making her own decision, she would have the final say over whether to pursue treatment. 

For some context, the book Doing Right even describes an incident where a Dr. was successfully sued because he gave a necessary blood transfusion in an emergency to a woman with a Jehovah's witness card in her purse! 

Another relevant case would be this: https://www.cbc.ca/news/canada/calgary/david-collet-stephan-meningitis-death-son-failure-provide-necessaries-appeal-1.4402665

Hope that helps!

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18 minutes ago, Llamastan said:

 

For some context, the book Doing Right even describes an incident where a Dr. was successfully sued because he gave a necessary blood transfusion in an emergency to a woman with a Jehovah's witness card in her purse! 

Another relevant case would be this: https://www.cbc.ca/news/canada/calgary/david-collet-stephan-meningitis-death-son-failure-provide-necessaries-appeal-1.4402665

Hope that helps!

I'm in my fourth year of residency and have been involved in emergency treatment for many people, and as far as I know no one ever looks in their wallet! Sometimes a paramedic or someone at the hospital will look at a wallet to try to identify a person, but as a doc I haven't looked in anyone's wallet. Most of the time their belongings are put away anyways. Very interesting that someone was sued for not seeing the card in the patient's wallet since it is not standard practice to look through people's wallets!

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9 minutes ago, MD2015:) said:

 I'm in my fourth year of residency and have been involved in emergency treatment for many people, and as far as I know no one ever looks in their wallet! Sometimes a paramedic or someone at the hospital will look at a wallet to try to identify a person, but as a doc I haven't looked in anyone's wallet. Most of the time their belongings are put away anyways. Very interesting that someone was sued for not seeing the card in the patient's wallet since it is not standard practice to look through people's wallets!

I actually went back and double checked Doing Right's references for this, because it seemed a bit odd. It does look like the Dr. was aware of the card (which was unsigned and undated) when he did the transfusion, because a nurse checked her wallet earlier.  I should have clarified that earlier! Also, the woman was unconscious and would have died without the procedure. Still, I think it's interesting that even an unsigned card is considered enough consent to let someone die. 

Link to the case is below: 

http://eol.law.dal.ca/wp-content/uploads/2013/05/malette-v-shulman-et-al.-72-OR-2d-417.pdf

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19 minutes ago, Llamastan said:

I actually went back and double checked Doing Right's references for this, because it seemed a bit odd. It does look like the Dr. was aware of the card (which was unsigned and undated) when he did the transfusion, because a nurse checked her wallet earlier.  I should have clarified that earlier! Also, the woman was unconscious and would have died without the procedure. Still, I think it's interesting that even an unsigned card is considered enough consent to let someone die. 

Link to the case is below: 

http://eol.law.dal.ca/wp-content/uploads/2013/05/malette-v-shulman-et-al.-72-OR-2d-417.pdf

It looks like she did sign the card but did not date it. Super interesting case thanks for the link. I feel like someone would not go to the trouble of getting the card, signing it, and carrying it around if it was not their wishes. If their beliefs had changed they would likely remember to take the card out of their wallet. I wouldnt want to be the doctor in that situation tho! I'm not really sure if there is a right answer to this case. Very very interesting

...another thing that is interesting is that the card said "i fully realize the implications of this position" but it doesnt say what the implications include....so then there is some question as to does she know all of the consequences of refusal (renal failure requiring dialysis, living with an anoxic brain injury, death, etc). If the card actually said i fully realized the implications including death then maybe that would make it look like there is fully informed refusal..I dont know...

( ""As one of Jehovah's Witnesses with firm religious convictions, I request that no blood or blood products be administered to me under any circumstances. I fully realize the implications of this position, but I have resolutely decided to obey the Bible command: 'Keep abstaining ... from blood.' (Acts 15:28, 29). However, I have no religious objection to use the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer's Lactate or saline solution."" )

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Wow! Awesome and really helpful responses :wub:

Definitely think that if you can't get a hold of anyone fast enough and if you take the time to consult with any other physicians available you can't be sued for doing a blood transfusion on an unconscious 3-y/o who would die otherwise! 

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