To transfuse or not to transfuse...

[TonesRN]

I sense a little frustration coming from you...don't beat yourself on the head.

I thought the purpose of this forum was for each of us to present our decisions and reason them through. I know we have to respect the patient's values, but the problem in this situation is I would not feel comfortable "pigeon holing" the patient into what we presume all JWs would decide unless the patient explicitly told me that he/she would never accept blood transfusions. The original poster posted this b/c it is a complex "grey" scenerio and I think the purpose was for us to generate discussion, work as a team and look at the problem through different eyes. I think we are all doing that:)

 

Thanks wanttobedoc. And I do appreciate and value your comments. However, my only aim is to EDUCATE people about how the law works. This scenario is truly difficult for many to decide what to do. I only want to inform you where you would stand from a legal perspective. Hopefully, you will take my points into consideration when placed in this scenario.

[Jochi1543]

You ALWAYS have to respect and uphold a patient's values and not YOUR OWN values. If not, you are certain to face legal rammifications (in this scenario at least)!!!

Yeah, apparently it doesn't work if your patient wants birth control or an abortion though, because then you are GOD and can do whatever you please.

[wanttobedoc]

Thanks wanttobedoc. And I do appreciate and value your comments. However, my only aim is to EDUCATE people about how the law works. This scenario is truly difficult for many to decide what to do. I only want to inform you where you would stand from a legal perspective. Hopefully, you will take my points into consideration when placed in this scenario.

Thank you TonesRN, I do appreciate and hear your points but I don't think fear of litigation should over power a doctor's judgement when it comes to giving a potentially life saving intervention. I realize we need consent and ideally we get that directly from the patient, a substitute decison maker, living will, or at the very least a JW card in the wallet stating "NO TRANSFUSIONS" or knowledge of prior expressed wishes that are hopefully in writing. I do realize the legal implications though, and thank you for this. I think there are valid "arguments" on both sides but for me, I'd rather be in court for saving a person's life than contributing to his/her death. Unless it is explicitly in writing NOT to do it, then I would rather accept the consequences of erring to save lives b/c that is what healthcare team members are trained to do. I'm sure there would be many docs that would agree with you, but there are also many that would agree with me I'm sure. Very grey situation in deed....

hopefully not an everyday occurrence:)

[The Law]

An interesting thought is what if a person was a JW... their family wasn't, and you did not engage in life saving procedures? What if their family sued you for that?

 

All in all, I think doctors should focus more on ethical judgement before they think about the law. Of course, the law must also be thought of since it's the doctor's reputation/career/money on the line.

[positiveoutlook]

I don't think fear of litigation should over power a doctor's judgement when it comes to giving a potentially life saving intervention.

 

You shouldn't be thinking about the law, you should be thinking about what the patient wants. Now while you may believe in using 'any means necessary' to save a patient, this isn't what the majority of JW's would want (with respect to blood transfusions that is). Why would you still transfuse a JW patient if you didn't know what he/she wanted? Isn't it reasonable to assume that the majority of JW's do not want a blood transfusion? So if you really wanted to respect the beliefs (when the direct wishes aren't known) of your JW patient, why would you choose to transfuse (when probably on a very small percentage would actually want you to)?

 

The reason, IMHO, is because you are seeing the situation through your eyes, and not the eyes of a JW patient. If you are playing the odds game, the majority of JW patients would not want a blood transfusion and if you are choosing to give it, then you are deciding to side with the minority. I don't think that you are really thinking of what is best for THESE types of patients.

[wanttobedoc]

The reason, IMHO, is because you are seeing the situation through your eyes, and not the eyes of a JW patient. If you are playing the odds game, the majority of JW patients would not want a blood transfusion and if you are choosing to give it, then you are deciding to side with the minority. I don't think that you are really thinking of what is best for THESE types of patients.

I hear what you are saying, but from my view point "life vs death" is too severe of an "odds game" to play. I believe I am thinking of it from the patient's and his/her family perspective. If I don't have it stated to me in writing or verbally from the patient or a reliable alternate that this person absolutely does not want a transfusion, then I don't think this big of a decision should be made just b/c of what the "majority" of JWs state. Perhaps when confronted with a death vs life consequence not every JW would make the choice that we think they would make. Anyway, I have no more to say on this subject...I think all view points have pros and cons....and as I've already stated this is not a "normal" scenerio. I think the doc should have out right asked the JW when he/she was still conscious what his/her views are on blood transfusions, then the points were are debating would not even by an issue. Thorough interviews, medical histories etc....are key, and if this patient had been well known to the doc, I'm sure this would have come up and charted.

[eise]

Sorry, I don't mean to press this issue any further but I just can't believe this is even an argument! I would NEVER go to a physician that chooses not to treat me because most people in my situation would not want the treatment. What about me? what do i want? YOU don't know. SO as my physician, pls do not assume what I want based on my values and beliefs, unless I have explicitly stated that I do not want certain treatments. Until you can survey 1000 JW's and they all tell you they would not want blood transfusions (which i doubt), then I would ALWAYS err on the side of caution. Even if only 1% would accept transfusions, whose to say your patient isn't in that 1%? As many posters have noted, people often deviate from their religious tenets.

 

If you are worried about the law, do you not think you could justify to a court of law that "i did not know the wishes of this patient and did not want to assume, based on their religion, that they wanted to die so i saved their life so that he/she could express his/her true wishes to me." honestly, i think you would be less likely to be found negligent than if you were telling the judge "i assumed he/she did not want the treatment so i let him/her die."

Is this not obvious?

 

p.s. my nanny is a JW who would prob consent to a blood transfusion. TonesRN, you just killed her. thanks.

[temp_degoo]

I didn't read al the above posts, but if she were in a coma my first step would be to identify a substitution decision maker and go from there.

[TonesRN]

I would NEVER go to a physician that chooses not to treat me because most people in my situation would not want the treatment. What about me? what do i want? YOU don't know. SO as my physician, pls do not assume what I want based on my values and beliefs, unless I have explicitly stated that I do not want certain treatments. Until you can survey 1000 JW's and they all tell you they would not want blood transfusions (which i doubt), then I would ALWAYS err on the side of caution. Even if only 1% would accept transfusions, whose to say your patient isn't in that 1%? As many posters have noted, people often deviate from their religious tenets.

 

If you are worried about the law, do you not think you could justify to a court of law that "i did not know the wishes of this patient and did not want to assume, based on their religion, that they wanted to die so i saved their life so that he/she could express his/her true wishes to me." honestly, i think you would be less likely to be found negligent than if you were telling the judge "i assumed he/she did not want the treatment so i let him/her die."

Is this not obvious?

 

p.s. my nanny is a JW who would prob consent to a blood transfusion. TonesRN, you just killed her. thanks.

 

I was content leaving this thread as it is. We each have our own values and beliefs about how we would go about these 'touchy' situations. But apparantly, certain people attempt to single people out and try to pass judgment for holding a particular belief. In the end, I am all about upholding the patient's values. You, on the other hand, are using YOUR values as to what JW patients want.

 

Based upon what I know about JW patients, the vast majority would never want a blood transfusion. I would still do everything possible to save the patient that didn't require a blood transfusion. I would not pass my values of wanting 'everything done' (including transfusion of blood) on a group that I know is hugely opposed to this intervention. By infusing the patient, you are doing just this. I would say that it is you who is not upholding the patients values.

 

You are right, I don't know what this particular patient would want done. But neither do you. You speak of 'erring on the side of caution', but you are choosing an intervention which the VAST majority of JW's oppose. That is hardly being cautious in my opinion.

 

p.s. If your nanny was the patient in this situation, I would NOT transfuse her. And I would NOT have an ounce of guilt. I would feel that I did everything 'possible' for this patient and did not use my values in place of hers. Moreover, the legal system would support my decision (of not transfusing) and would not find me negligent. Look into this if you wish.

[TonesRN]

I didn't read al the above posts, but if she were in a coma my first step would be to identify a substitution decision maker and go from there.

 

Agreed. Having further insight into what this individual patient truly wants will make this scenario much easier to deal with.

[Smurfette]

All in all, I think doctors should focus more on ethical judgement before they think about the law. Of course, the law must also be thought of since it's the doctor's reputation/career/money on the line.

 

This is an interesting comment. It SEEMS to assume that the law is some arbitrary rule out there that we are forced to follow. Laws are typically representative of the moral values of society. What the law says is indicative of what the majority of people in that society feel is correct. Therefore, law should be a guide to understanding what most people believe is right or wrong.

[The Law]

This is an interesting comment. It SEEMS to assume that the law is some arbitrary rule out there that we are forced to follow. Laws are typically representative of the moral values of society. What the law says is indicative of what the majority of people in that society feel is correct. Therefore, law should be a guide to understanding what most people believe is right or wrong.

 

By law I was referring to the litigative issues surrounding decisions a doctor must make. Of course, laws that are criminal laws must be followed by anybody who lives in the country.

And you are right, regarding laws... they usually do indicate what the majority of people in society feel is correct. That does not necessarily make all laws correct though.

[Jochi1543]

I wonder if JW doctors are allowed to refuse to give blood transfusions.

 

Something tells me it would be perfectly legal for them to do it.

 

I thought US was the only country where political correctness was spinning out of control, but apparently not.

[tallguy408]

I think you would be legally and morally justified in giving a transfusion. NO, the majority of JW's would not want the transfusion. NO, it would not be reasonable to assume that they would.......HOWEVER, the decision to not give one and let the patient die is not the safe, moral, or most legally sound decision. If you look at this issue in a different light, this is the Terry Schiavo case in disguise. You have a patient unable to communticate his/her will, and you may not be able to discern the will from family if they are not available or if this is an emergency situation. The LEGALLY, MORALLY safe bet is to err on the side of LIFE, not DEATH when there is ANY AMBIGUITY as to the wishes of the patient. ANY legal system would agree with this.

[med84]

Hey everyone, I just sat here and read this whole thread very quick and I think everyone here placed very interesting perspectives....but really I think the best solution is a combination or rather blend of all the different perspectives...

 

I think in medicine we are going to face a lot of these gray area dilemma’s and there is no single way of doing things........The best way to go about it is to sit and weight out all these different possibilities that everyone here greatly mentioned.

 

From my perspective, as a physician you are obligated to give a patient the best health care possible and try to alleviate their illness’s as best as you can WHILE at the same time in keeping with their wishes and values. Now in this scenario you know the patient is a JW, but you don’t know his/her actual predisposition regarding a transfusion and you are probably running out of time... I think you will have to quickly assess the situation, you have to find out through old medical records, or through family or friends what HER/HIS beliefs and interests where when he/she was last competent. At this point if you fail to find any such information and you are in an emergency OR, you have to use your judgment. There's no harm in consulting with other physicians to try to find the best choice to 'do no harm' to this patient while at the same time keeping with her/his best known wishes. And as long as you record everything you have done and the whole process, you should have no fear of litigation regardless of the decision you choose to follow, and I think its just whatever hunch and feelings you and your colleagues have at that time will dictate your final decision… There is no always right or wrong way to do anything...... I hope this perspective was insightful.

 

Med84

[positiveoutlook]

I think you would be legally and morally justified in giving a transfusion. NO, the majority of JW's would not want the transfusion. NO, it would not be reasonable to assume that they would.......HOWEVER, the decision to not give one and let the patient die is not the safe, moral, or most legally sound decision. If you look at this issue in a different light, this is the Terry Schiavo case in disguise. You have a patient unable to communticate his/her will, and you may not be able to discern the will from family if they are not available or if this is an emergency situation. The LEGALLY, MORALLY safe bet is to err on the side of LIFE, not DEATH when there is ANY AMBIGUITY as to the wishes of the patient. ANY legal system would agree with this.

 

What you are stating is that a blood transfusion is synonymous to life. It is not. They are NOT one and the same. A blood transfusion is equal to a blood transfusion. Do not confuse the means with the end. I would agree that you should always err on the side of life and not death. Do not assume that people who choose to not give the blood are choosing death for the patient. That is absurd. You CANNOT use your values in place of a JW patient. Everyone who chooses to give a blood transfusion is doing just this.

 

This intervention is not legally safe. It is the legally UNSAFE course of action. I would encourage you to take a health law course and you will learn the same thing. The odds are that you WILL be held liable in a civil suit. Do not state what you assume to be justified and correct without first having insight into how the legal system actually works. I do not have the time to teach you, but if you were to look into this yourself further, you will see that you will in fact be held liable if you decide to transfuse.

[positiveoutlook]

You have provided much insight and thought. Your position on the matter is appreciated and non-judgmental. Thanks.

[positiveoutlook]

Hey everyone, I just sat here and read this whole thread very quick and I think everyone here placed very interesting perspectives....but really I think the best solution is a combination or rather blend of all the different perspectives...

 

I think in medicine we are going to face a lot of these gray area dilemma’s and there is no single way of doing things........The best way to go about it is to sit and weight out all these different possibilities that everyone here greatly mentioned.

 

From my perspective, as a physician you are obligated to give a patient the best health care possible and try to alleviate their illness’s as best as you can WHILE at the same time in keeping with their wishes and values. Now in this scenario you know the patient is a JW, but you don’t know his/her actual predisposition regarding a transfusion and you are probably running out of time... I think you will have to quickly assess the situation, you have to find out through old medical records, or through family or friends what HER/HIS beliefs and interests where when he/she was last competent. At this point if you fail to find any such information and you are in an emergency OR, you have to use your judgment. There's no harm in consulting with other physicians to try to find the best choice to 'do no harm' to this patient while at the same time keeping with her/his best known wishes. And as long as you record everything you have done and the whole process, you should have no fear of litigation regardless of the decision you choose to follow, and I think its just whatever hunch and feelings you and your colleagues have at that time will dictate your final decision… There is no always right or wrong way to do anything...... I hope this perspective was insightful.

 

Med84

 

You have provided much insight and thought. Your position on the matter is appreciated and non-judgmental. Thanks.

 

(Sorry, I was refering to this post!)

[tallguy408]

positive outlook,

 

In this scenario, it should be implied that the blood transfusion is essential to the continued life of the patient. If it were not, then there is no ethical scenario here at all, and this whole debate is absurd. If the transfusion were simply one of many options available to save the life of this patient, obviously you would not risk giving blood to someone most likely to refuse it. The implication here is that the transfusion is absolutely vital. You give it, the patient has a chance of surviving. You don't, they die. Thus, no transfusion does = death, transfusion=life, and my previous arguments, moral and legal stand as correct. If your version of events were true, and no transfusion did not mean death, obviously you would be correct. I am fairly knowledgeable in health law myself. You do make good points, but in the very difficult scenario proposed, I think you will see that my actions would be best.

 

Word.

[NorthernDude]

In regards to whether you'd know if someone was a devout JW or whatnot to know whether or not they would refuse a blood tranfusion if they are able:

I've worked in a retail store for years and have seen the contents of many peoples wallets. Most devout JW's that I've seen carry a prominent card in their wallet that says NO Blood Products or Tranfusions or something. Now granted, a card is not considered binding by law and often in a case like that the family would get a say which complicates things hugely.

[temp_degoo]

If the individual chooses that THEY don't want the blood transfusion, it is their wish, and the blood transfusion should not be performed. They have taken the time to advance-plan and decide what they think is best for them, and you cannot go against this.

 

The issue as it pertains to the child however, I'd go ahead with the procedure, only after trying to convince the parents and even bringing in a court appointed substitute decision maker (if time allows). The law sides for life in this case though. Not in the one above, in fact you can get sued if the patient themselves have explicitly said, no transfusion for ME.

[wanttobedoc]

If the individual chooses that THEY don't want the blood transfusion, it is their wish, and the blood transfusion should not be performed. They have taken the time to advance-plan and decide what they think is best for them, and you cannot go against this.

 

The issue as it pertains to the child however, I'd go ahead with the procedure, only after trying to convince the parents and even bringing in a court appointed substitute decision maker (if time allows). The law sides for life in this case though. Not in the one above, in fact you can get sued if the patient themselves have explicitly said, no transfusion for ME.

 

Great thoughts and agree with what you have said, however the original posted dilemma did not specify that the patient formally refused a blood transfusion. With no formal documentation (wallet card or previously recorded refusal) the doctor does not have a lot to go on except to do everything in his/her power to prolong the patient's life without a blood transfusion until further info can be obtained from either family or perhaps the patient will come out of the coma? If it comes right down to the crunch and tranfusion = the difference between life or death, as I have previously posted, in my opinion, I would transfuse to perserve life and deal with the consequences (if there are any). It is not my fault that the patient does not have any formal documentation leading me to think I should have done otherwise. But, it is my fault (as the doc) for not taking a better medical history and finding all of this stuff out before the patient went into coma (persuming I've had a previous history with the patient). Sometimes, it is the questions we ask, that are our strongest interventions as a doc. As for the questions we don't ask or perhaps are in a rush and forget to ask, the answers to these could be the pieces of the medical puzzle that are missing....and lead to medical complications and/or dilemmas later. Just my thoughts and opinion .....this thread has been very active!

[katerade]

The Wikipedia article on this topic is interesting:

 

http://en.wikipedia.org/wiki/Jehovah%27s_Witnesses_and_blood

 

Read the paragraph on 'Acceptance within the JW community'. Apparently 12% of JW's would accept a transfusion in a life or death situation. If you transfuse, 90% of the time your patient will be very unhappy with your actions and may feel violated enough to take you to court. However, 10% of the time YOU WILL NOT HAVE LET A HUMAN BEING DIE BY WITHHOLDING CARE. If there is no possible way to determine the patients OWN wishes (and not just the doctrine of the religion that he/she belongs to) then you would not be unjustified in giving a transfusion.

[AMmd]

I successfuly convinced a JW that blood transfusion is not bad. She said that blood transfusion was not accepted by God and was written in the Bible (wrong!) and I showed her that this was wrong and she realized that their bible is very much different from The Bible. But then again this was a religious debate

[wanttobedoc]

I successfuly convinced a JW that blood transfusion is not bad. She said that blood transfusion was not accepted by God and was written in the Bible (wrong!) and I showed her that this was wrong and she realized that their bible is very much different from The Bible. But then again this was a religious debate

yes...and according to a recent Maclean's magazine article JW's views on what is "acceptable" treatment and what is not considered acceptable has changed over the years. Not too long ago organ transplants and vaccinations were unacceptable to their religion, but that has changed. Apparently (according to this Maclean's article) the only way JWs keep up on what they are allowed to do is through specifications listed in their "Watchtower" magazine...

I'm sure one of these days, the blood transfusion "rule" will change for them too.