A dilemma

[DOC_Ma]

Hi I have been thinking about this senario for a while now, just wondering what are some of your opinions on this issue.

 

Senario1: If a person is jehovah's witnesse and refuses blood transfusion but will die shortly without it. What do you do?

 

My answer is I would do whatever I can to persuade this person to accept blood transfusion but if he still insists not doing it, I will have to respect his wish.

 

Senario2: If a 2 months old kid is in desparate need of blood transfusion but his parents Jehovah's witnesses and refuse giving him the treatment what do you do?

 

For this question, I am troubled by this one. Any ideas?

[astrogirl]

Scenario 1: Pretty sure that's the right thing to do. You can try to persuade them, but it's their decision.

 

Scenario 2: I think in this case you need to get a court order and have a temporary guardian appointed who takes the place of the parents in making decisions for the child so that you can give the child the blood transfusion. If the child was, say, an older teenager, the situation could get a bit stickier. I think it's not unheard of for a judge to decide that a much older child can make the decision to refuse medical treatment for religious reasons.

 

But then there's the issue of what if the child will die without the blood transfusion before you can get the legal issues sorted out. I'm not sure what you do then. Probably someone else on here knows. But those are my ideas, for what they're worth.

[orange123]

Scenario 1: Pretty sure that's the right thing to do. You can try to persuade them, but it's their decision.

 

Scenario 2: I think in this case you need to get a court order and have a temporary guardian appointed who takes the place of the parents in making decisions for the child so that you can give the child the blood transfusion. If the child was, say, an older teenager, the situation could get a bit stickier. I think it's not unheard of for a judge to decide that a much older child can make the decision to refuse medical treatment for religious reasons.

 

But then there's the issue of what if the child will die without the blood transfusion before you can get the legal issues sorted out. I'm not sure what you do then. Probably someone else on here knows. But those are my ideas, for what they're worth.

 

I agree w/ Astrogirl A court order would be necessary for a 2 month old baby. NOW, the tricky thing is, with an older child. say preteen. I believe there was a case in winnipeg or somewhere in manitoba this past summer, whereby one girl was give a blood transfusion (? or sth along those lines) against her wishes and those of her family, because a judge ordered it. She equated that action as being akin to "rape" . I don't recall any further specifics about the case, but I think a precedent has been set. thoughts?

[ontariostudent]

Every hospital has an ethicist, and no scenario is totally new. When in doubt, ask someone else.

[skp1187]

1st scenario: I would first determine if the patient was competent (i.e. had capacity). Also rule out other external factors such as depression or suicide that may be influencing the patient's refusal of blood. If I believed that the patient fully understood and appreciated the situation, and the risks involved (death), then due to important principle of autonomy, I would have to respect his or her decision to refuse treatment.

 

2nd scenario: I agree with the others. Get a court approval for finding a substitute decision maker and make sure that that person makes a decision that would be in the patient's best interest.

[Jochi1543]

IIRC, 2 doctors that agree on a treatment course can override the parents' decision in an emergency like that. Can someone confirm?

[2014?]

In a previous job, I spent a lot of time dealing with the hospital liaison committee for Jehovah Witnesses. To the best of my knowledge, most provinces have one, and they can be great resources and mediators between health care providers, patients and families.

 

From anecdotal stories and knowledge about how the situation usually worked at the hospital where I worked, there are a lot of factors and situational things that will effect both scenario.

 

In the first example- I think you would have to consider where, how and why this person was accessing the health system. There is a big difference between a jehovah witness scheduled for elective surgery who has a big intra/post op bleed vs. an unconcious patient admitted to the ER with some kind of trauma. In the surgery example, the patient typically signs a refusal "consent form" indicating what blood products/components they are willing to accept. The forms that I've seen CLEARLY state that by signing the person is acknowledging that if they get in a situation where these products are deemed necessary to save their life, they will not be used. In an emergency its a stickier situation, a lot of people carry advanced directives, but these are sometimes not up to date, unsigned, there is not a clear consensus from the family, if they can even be reached in time.

 

 

In the second example its even more complicated. With kids I believe physicians can overrule the patients wishes. If time permits, I believe a court order should be obtained and the kids are temporarily in custody of the province while the transfusion is administered. This has been debated in the courts, especially in older children. 2 cases that come to mind were a teenager with cancer, (in BC or AB) I believe that successfully won a case to make her own decision. Also recently, I think there was a case in BC with twins or triplets. I think Jochi is correct and in an emergent situation 2 physicians can make a concensus decision.

 

hahah... this was really lengthy- just happens to be the one ethical situation I know lots about!

 

I think its also important to mention that in elective situations- physicians don't HAVE to handle the care of jehovah witness patients.

[MedIn2010]

Scenario 1: Pretty sure that's the right thing to do. You can try to persuade them, but it's their decision.

 

I don't think you can really persuade the patient if they are capable. I don't think a doctor has any right to try to change the patients beliefs, especially when they are certain that the patient understands the consequences.

[astrogirl]

"Persuade" is probably the wrong word. What I meant by that was "make sure they understand that there is a huge risk that they will die without a blood transfusion". And if they understand the risk, well, then, it's their decision to make.

[MedIn2010]

I concurr.

 

Lol. I suspected that's what you had in mind, astrogirl, but wanted to clear it up just in case.

 

Edit: Admittedly, I'm sure a part of me would want to persuade them... but yeah, I think that would be unethical.

[ndiggity]

For the second scenario, from what I have been told by doctors, if its an infant or baby and the parents refuse a transfusion, social services can intervene temporarily and allow the transfusion. Alot of the time, the parents actually don't mind that this happens, because the parents feel they fufilled their religious beliefs by denying the transfusion, and their child is still saved. We spent alot of time talking about this in our ethics class.

[w8kg6]

For case 1, you have to educate the patient about the possible outcomes of ALL treatment types. This holds true for pretty much any treatment, not just those that are life saving. If they are capable and competent, as well as educated, yet they still choose to forgo a treatment of any kind, the best you can do is help them with any dying wishes.

 

For situation 2, the parents do NOT have the right to forfeit a life saving treatment for their child. In fact, only in very extreme cases are children able to decline life-saving treatment for themselves, and even in these cases it is only because the children (or, minors) have demonstrated an ability to truly comprehend the consequences and finality of their decision. Never in ANY case are parents allowed to refuse a treatment that will prevent unreasonable or unnecessary harm for their child.

[DOC_Ma]

Great great answers guys! Now Suppose a third senario, what if an adult is in coma and his religion is against blood transfusion, who is the legal person to decide whether or not he gets blood tranfusion? Is that usually the spouse parents or no one but doctors do whatever (even against his wish if he were awake) to save his life?

[AndreaM]

Great great answers guys! Now Suppose a third senario, what if an adult is in coma and his religion is against blood transfusion, who is the legal person to decide whether or not he gets blood tranfusion? Is that usually the spouse parents or no one but doctors do whatever (even against his wish if he were awake) to save his life?

 

If someone is in a coma then a TSDM is appointed (temporary substitute decision maker) who is deemed most likely to have known what the person would have decided for themselves. Often this person is a close family member, but may be court appointed, depending on circumstances. The doctor would not be the TSDM.

[rmorelan]

If someone is in a coma then a TSDM is appointed (temporary substitute decision maker) who is deemed most likely to have known what the person would have decided for themselves. Often this person is a close family member, but may be court appointed, depending on circumstances. The doctor would not be the TSDM.

 

exactly - and if court appointed that TSDM would try to determine what the patient would have wanted based on everything he/she could find out about them and act accordingly.

 

This isn't a route to override known patient wishes

[DOC_Ma]

Thanks guys this clears up everything!

[LookingForInfo]

I agree w/ Astrogirl A court order would be necessary for a 2 month old baby. NOW, the tricky thing is, with an older child. say preteen. I believe there was a case in winnipeg or somewhere in manitoba this past summer, whereby one girl was give a blood transfusion (? or sth along those lines) against her wishes and those of her family, because a judge ordered it. She equated that action as being akin to "rape" . I don't recall any further specifics about the case, but I think a precedent has been set. thoughts?

 

I agree with everyone above, but just to add my two cents from what I've read from a few different sources...

 

Case 1: (not really giving an answer, but just adding another twist to the situation since this scenario has already been well covered). A young patient (say, teens) is admitted unconscious into the hospital after a severe car accident and needs a blood transfusion within the hour in order to survive. After rifling through the patients wallet for identification, donor card, etc. you find a Jehovah's Witness card proclaiming that they would not like to receive any blood products in any event. However, in order to considered legally valid (I think this is the case), the card must be signed by two witnesses and dated by all parties. This card has only the name of the patient, how do you proceed?

 

Case 2: I think I've read briefly about the case Astro girl is talking about. With a young child, I would say that you'd have to get a court order to obtain temporary guardianship to be able to do anything. For an older child, the case I remembered was a 12-13 year old girl (so clearly a minor) who refused blood transfusion. Through assessment, I believe the court ruled in her favour along the lines that she "had reached mental and spiritual maturity beyond her years" and fully understood the implications of her decision.

 

In an older child/young teen (minor) I think the patient would have more say in the matter and would be able to make the decision if it was deemed that they were of appropriate maturity. Not sure how to proceed in an emergency situation though, because anything that involves the court involves time...

[rmorelan]

I don't think there really was precedent set in the cases - the courts always had the power to do what they did, and have used it in the past for other similar things. They also have to show that the parents are not acting in the child's best interests and that the child is not mature enough to properly evaluate the options - this is also standard.

 

Must have been tough to decide the cases though!