Description

A 44-year-old Jehovah´s Witness received blood transfusions during treatment for necrotizing pancreatitis.

Key Lessons

Refusal of blood and blood products must be respected and may only be overridden by a court order, in non-emergency situations.
If possible, the consent discussion should be conducted before the patient undergoes procedures or medications that limit his/her ability to reason and/or communicate.
Consent given by proxy should be confirmed (if possible) and documented.
When consent for a procedure occurs in the midst of an emergency, revisit and document the consent process for similar subsequent procedures.

Clinical Sequence

A 44-year-old woman was admitted to the hospital with necrotizing pancreatitis. She had significant blood loss and a dropping hematocrit. With the severity of her condition, death was imminent. Both the resident and the attending were aware the patient was a Jehovah's Witness. She had been intubated and was in ICU where she was told by the attending that he would not perform surgery without a blood transfusion and that, without the surgery, she would die.

The insured attending felt the patient was competent when she nodded her consent for a blood transfusion. He contacted the hospital's in-house counsel, who recommended doing “what was medically necessary.” The patient’s husband, who had a handwritten note from his wife stating “please don't let me die,” gave oral permission for the blood transfusion.

After permission was obtained, the patient was taken to surgery and given blood transfusions. Over a four month hospitalization, the patient underwent more than 20 procedures with more than 30 transfusions.

Claim Sequence

The patient filed a lawsuit against the resident, the surgeon, and the institution alleging that the transfusion of blood products against her will constituted battery, and a civil rights violation. Prior to trial, the institution was dropped from the suit.

Disposition

The case went to trial where the jury found in favor of the defendant physicians.

Analysis

Family members and Jehovah's Witnesses testified that the blood transfusions disregarded the patient's wishes.
Generally, refusal of blood and blood products by a competent adult must be respected and may only be overridden by a court order, in non-emergency situations. Involving the institution's legal counsel or medical ethics committee can help clarify the decision making during emergencies.
If previously treating providers knew this patient’s wishes about blood transfusion, discussion and documentation of her preference could have been helpful in this emergency.
Such a discussion should be considered for patients with chronic diseases that may lead to emergency situations (e.g., such as whether an asthma patient would want to be intubated).
Consent was obtained from the patient while she was intubated and sedated. In her complaint, the patient argued that the consent process should have taken place before her intubation, or that her sedation should have been “lightened” to enable her participation.
If possible, the consent discussion should be conducted before the patient undergoes procedures or drugs that limit his/her ability to reason and/or communicate. A non-spoken/non-written consent (e.g., nodding) should be carefully documented in the record along with the names of any identified witnesses.
Based on a note written by the patient to her husband, her husband gave permission for her blood transfusion.
Any mentally competent person 18 years or older has the right to consent to his/her own medical treatment, and is the only person whose consent is valid. Consent given by proxy should be documented (i.e., a copy of her note should have been added to her medical file).
This patient was treated with multiple procedures and transfusions based on a single act of consent.
Generally, clinicians are not required to engage patients in an informed consent discussion for each occurrence of a repetitive procedure or treatment, as long as the clinical indications and risks are unchanged. However, when the initial consent occurs in the midst of an emergency, and the treatment consented to must be repeated during subsequent care, the consent process should be revisited and documented.