Ethical Dilemma

[mglick]

Hi All Nurses,

I am a student nurse and I am looking for nurses point on this case.

A 20-year-old, 32-weeks pregnant was the driver of a car involved in a single-vehicle collision. She was taken to the ED was alert and oriented, Glasgow Coma 15/15. Her initial complaints were lightheadedness, weakness, left shoulder pain, and severe abdominal cramping that started immediately following the car accident. She had a past medical history of sickle cell disease and no previous pregnancies. Her lungs were clear bilaterally. Juana's heart rate was 90 beats per minute (bpm), her respiratory rate was 28, and her initial blood pressure (BP) was 130/80, and fetal pulse rate was 90. Once the cervical spine films were taken and the flat board was removed, her BP reflected orthostatic changes

of 100/60 and pulse of 120 bpm. Her labs indicated internal bleeding.

The plan of care was an immediate blood transfusion and an emergency C-section. However, the patient was a Jehova's Witness and refused the proposed plan of care.

As nurses, we have to honor the grant the patient's wish. However, shouldn't the medical team obtain a court order to save the baby? (The mom gave birth to a stillbirth) What is your take on this?

Thank you.

[Good Morning, Gil]

If patient refused blood transfusion, she needs to be told the consequences of that decision. That's a crappy situation as that baby is 32 weeks and is a viable life. I guess we don't have the info as to how bad the accident was, and what damage was done to baby anyway, but if a woman refuses, she refuses. It's an ethical dilemma for sure, but the law is not based on ethics, and the law says, it's a woman's choice. So, there you have it. (though justice is an ethical term and is what the law was originally designed to do, that's not what our legal system does anymore. It's designed to win, and the goal of trial lawyers is to win, not bring about justice, but I digress lol).

[psu_213, BSN, RN]

Most abortion laws consider viability and gestational age. There's a big difference between terminating an 8 or 10-week-old fetus, that can't live outside the uterus, and letting a 32-week-old fetus, that could otherwise survive, die. Jehovah's witnesses generally don't have a problem with C-sections, just blood transfusions. Other options should be offered, like a stat c-section without the blood transfusion, before it's chalked up to patient refusal.

I totally agree that other options should be explored and presented to the pt. However, the woman's autonomy in the situation is always going to take precedence.

[JustBeachyNurse, LPN]

I know that some teaching university medical centers offer bloodless surgery for certain ID patients (such as HepB and HIV positive) that can also be used in a variety of other circumstances such as normal and high risk obstetrics. Here is an example: Techniques

If the patient is not near a facility that offers bloodless surgery options then the decision is totally up to the patient. Your patient is the mother not the child. It is difficult to watch. Sometimes brainstorming and scouring available resources is necessary to see if there are any viable options to blood transfusion. A true Jehovah's witness believes with all their heart that accepting a blood transfusion is wrong and fully against their Bible teachings. There is no option. And the US Courts agree:

"The second case involved the then pregnant Witness Darlene Brown, who was forcibly transfused for the sake of her 34-week fetus. On December 31, 1997, the Illinois Appellate Court explained its decision by saying that "a blood transfusion is an invasive medical procedure that interrupts a competent adult's bodily integrity." The Appellate Court summarized its ruling by saying that "under the law of this State, . . . we cannot impose a legal obligation upon a pregnant woman to consent to an invasive medical procedure."" (source: Bloodless Surgery-Its Benefits Gain Recognition - Jehovah's Witnesses Official Web Site ) There are several other court decisions available that can be found in a simple online search.

Just because a patient's spiritual beliefs are not consistent with your own does not make them wrong. The patient in this case was the mother. She had every right to decline the blood transfusion, even if it meant that her and/or her unborn child's life was at risk. Our obligation is to ensure that the patient is fully informed of the risks and benefits of a treatment or procedure by the treating physician. If we cannot separate our own beliefs from the competent care of a patient then we need to be mindful enough to ask for a new assignment.

[Dixielee, BSN, RN]

Yes, that was a horrible situation and if I had been the patient, I would have done anything to save my baby, but it was not my baby. With the initial vital signs showing a fetal heart rate of 90, that baby was in distress from the beginning. Then the time between then and getting xrays, labs etc. back probably accelerated the baby's demise. At what point would the c-section have been successful in saving the mother and baby? Only God knows, and only he can determine what the proper course of action would have been. Tough dilemma for sure.

[KelRN215, BSN, RN]

Thank you Esme12.

What really threw me off with this case study is the religion. She refused the blood transfusion or any blood products because is is/was Jehovah's Witness. I understand that nurses have to grant the patient's wishes no matter what. However, my personal belief is that if she doesn't want to be saved at least let the medical team save the baby. By making the decision not to take the transfusion is the same as killing your own child. What happened to "do no harm" or advocating for your patient (the baby)?

The fetus is not your patient, the woman is. Surgery and blood transfusions without consent don't fit with "do no harm". You have done significant harm to the woman if you do these things and I don't think you'll find a court out there that would sign a court order to force a blood transfusion on a competent adult. I am familiar with court cases for children in need of blood transfusions whose parents are refusing based on religious grounds but cannot imagine a situation in which a competent adult's refusal to consent could be overridden by the courts.

As others have said, the woman should be counseled that her refusal of blood products may result in loss of pregnancy but it is still ultimately her decision. One thing sticks out at me from what you said here and that is "my personal belief". It's fine that that's your belief, but, sometimes, you have to be able to set your own biases aside. Jehovah's Witnesses, by and large, do not accept blood transfusions and refusal of transfusions is a fundamental part of their faith and it is this woman's right, as a JW and as a competent adult, to refuse any medical procedure for any reason.

[OCNRN63, RN]

Just because the patient in question refused the transfusion and ultimately lost the pregnancy does not in any way mean she didn't care about/love the baby. It's not like, "Oh well, if we lose the baby, we lose the baby."

Hospitals that provide bloodless medicine have it all over in spades when compared to regular hospitals on this issue. They understand methods of minimizing blood loss in surgery and regular medical treatment.

And why did the patient refuse surgery? If she was hemorrhaging profusely, what she first needed was volume replacement to maintain her BP and prevent circulatory collapse. I've known JW all my life, and I can't think of a one who would refuse an emergency C/S to save the baby. To me, your case study sounds flawed; it shows a lack of awareness of people of that faith.

[AMN74]

As an old time Peds nurse back in late 80s we had a kid (parents JW) that was bleeding out and was in desperate need of a blood transfusion. Of course the parents said no. Absolutely refused. They tried fluids, but without blood what good is the fluids? MD talked to parents extensively about the child dying if he did not get blood STAT. They still refused. MD got hospital lawyer to get a court injunction from a judge to give the blood, and we gave it. The child lived. Again that was more than 20 years ago and I do not know how they handle this situation now. Parents were not our patient, the child was. Parents had power to make decisions/guardianship of child, but found in court of law that they were not making proper choices for the child and in order to save the child's life, we did what we had to do...

[KelRN215, BSN, RN]

As an old time Peds nurse back in late 80s we had a kid (parents JW) that was bleeding out and was in desperate need of a blood transfusion. Of course the parents said no. Absolutely refused. They tried fluids, but without blood what good is the fluids? MD talked to parents extensively about the child dying if he did not get blood STAT. They still refused. MD got hospital lawyer to get a court injunction from a judge to give the blood, and we gave it. The child lived. Again that was more than 20 years ago and I do not know how they handle this situation now. Parents were not our patient, the child was. Parents had power to make decisions/guardianship of child, but found in court of law that they were not making proper choices for the child and in order to save the child's life, we did what we had to do...

This would still happen today but the OP's situation was not a parent refusing blood for her child but a woman refusing a blood transfusion for herself. I never had to give a blood transfusion despite a parent's refusal to consent but I know some of my colleagues at a pediatric hospital had had to in the past.

[Salisburysteak, BSN, RN]

I agree with Klone. What we as nurses may find wrong, the patient may not because of cultural/religious beliefs. We are taught to not judge our pts., but it is hard not to.

This brings up a question for others. Do you feel there should be more cultural/ religious diversity taught in Nursing school? I ask this because throughout my years working as a CNA and now nurse, I have seen people pretty ill-informed about other cultures and religions. Just my own opinion, I could be wrong.

[Merlyn]

Thank you Esme12.

What really threw me off with this case study is the religion. She refused the blood transfusion or any blood products because is is/was Jehovah's Witness. I understand that nurses have to grant the patient's wishes no matter what. However, my personal belief is that if she doesn't want to be saved at least let the medical team save the baby. By making the decision not to take the transfusion is the same as killing your own child. What happened to "do no harm" or advocating for your patient (the baby)?

She refuses the transfusion nothing anybody can do. It is her belief and her right. The baby is still not a separate human being. It is still attached to the mother. You can not say for sure that a transfusion will save the baby. The mother has the right, under the first amendment of the Bill of Rights, to refuse for the baby too. You stated that she was in her right mind. If she was judged insane it would be a different matter, maybe. But you would be hard press to find a judge willing to go up against the Jehovah's Witnesses. The personal belief of the nurse doesn't matter. This is the real world, Kid and welcome to it.

[PetsToPeople]

Most abortion laws consider viability and gestational age. There's a big difference between terminating an 8 or 10-week-old fetus, that can't live outside the uterus, and letting a 32-week-old fetus, that could otherwise survive, die. Jehovah's witnesses generally don't have a problem with C-sections, just blood transfusions. Other options should be offered, like a stat c-section without the blood transfusion, before it's chalked up to patient refusal.

Stat c-section and the resulting loss of blood and fluids in combination with internal bleeding? May save the baby but lose the mother.