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.

[cayenne06, MSN, CNM]

What is your opinion on this? It sounds like a homework assignment and I think you will get more discussion if you start the ball rolling yourself.

[JZ_RN]

I am a "pro-choice" person and I am a nurse. I believe that the consequences should be explained to the mother (possible death for her and her baby) and then let her choose, just like I believe a mother should be able to choose to remain pregnant or not. It is her body, her child, etc. If she has been given the consequences she is an adult and can make a decision (even if I necessarily don't agree with it, it's not my child, body, or life) and she has to deal with it.. (bring on the hate from people who wanna tell everyone else what to do) Patients deserve to know their options and consequences of each option, and be allow to make their own decisions when competent, that's the only ethical solution.

[Esme12, ASN, BSN, RN]

Welcome to AN! The largest online nursing community.

We are happy to help with homework but we won't do it for you. Are you supposed to interview a nurse? What do you think? What are YOUR personal beliefs? Have you looked up the law? What about "artificial" blood replacements or transferring to a bloodless surgical facility?

Tell me your thoughts and I'll tell what is legal, what we as nurses are obligated to do and what I personally think.

[mglick]

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)?

[BluegrassRN]

And how exactly are you going to "do no harm" in this situation? How are you going to save the baby? By forcing major abdominal surgery on a woman who does not consent to it. Let's think about that for a minute. You are going to tie her down, sedate her against her will, perform an abdominal surgery on her reproductive organs (which could affect her childbearing in subsequent pregnancies), ALL AGAINST HER WILL.

Really? If I say NO to a procedure on me, if I don't want a surgery or a treatment, you damn well better honor that wish. Consent exists for a reason. Just because someone doesn't chose the route that you or I personally would take does not mean that we can disregard their consent.

[chevyv, BSN, RN]

All of the fluff in this can be taken out and you'll still have the same question/answer. The patient was alert and refused so yes, you honor the pts autonomy. Unless of course you risk your license, knock her out with an IV pole and then......

[ckh23, BSN, RN]

The bottom line is the patient refused. In this situation you would need to come up with an alternative plan. Perhaps taking the blood transfusion out of the equation and just approaching the patient about an emergency c section would be better. They might be more agreeable to it if they are plans laid out about how they are going to minimize blood loss during the procedure.

[psu_213, BSN, RN]

A woman has a right to chose vis-a-vis her pregnancy. She has the right to terminate that pregnancy therapeutically (i.e. an abortion) with essentially no questions asked. So, would it not follow that she also has the right to refuse tx. even if it means that her baby will be lost if nothing is done?

I have issues with abortion--I'm not sure if it is morally acceptable for a woman to end here pregnancy in such a matter. However, the 'law of the land' is abortion is legal and woman has a right to choose. So, if a woman comes to the ER. As part of her workup, she is found to be pregnant. She tells you she just can't have the baby and she is going to get an abortion. You cannot scold her for that, tell her what a bad person she is, etc, etc. Same here. She is A&Ox3. She knows and understands what may happen if nothing is done. As ckh said, the team can make plans to minimize blood loss, etc., but in the end, the choice has to be hers.

[klone, MSN, RN]

As an OB nurse, I've watched a fetus die on the monitor because the woman and her husband refused to consent to a c-section because it was against their cultural beliefs/practices. We cannot force them into a procedure against their wishes. End of story. Autonomy.

[Not_A_Hat_Person, RN]

A woman has a right to chose vis-a-vis her pregnancy. She has the right to terminate that pregnancy therapeutically (i.e. an abortion) with essentially no questions asked. So, would it not follow that she also has the right to refuse tx. even if it means that her baby will be lost if nothing is done?

I have issues with abortion--I'm not sure if it is morally acceptable for a woman to end here pregnancy in such a matter. However, the 'law of the land' is abortion is legal and woman has a right to choose. So, if a woman comes to the ER. As part of her workup, she is found to be pregnant. She tells you she just can't have the baby and she is going to get an abortion. You cannot scold her for that, tell her what a bad person she is, etc, etc. Same here. She is A&Ox3. She knows and understands what may happen if nothing is done. As ckh said, the team can make plans to minimize blood loss, etc., but in the end, the choice has to be hers.

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.

[RNsRWe, ASN, RN]

OP, you're forgetting that your patient is NOT the baby, as you stated....it's the pregnant woman. And if you disregard her wishes and force an unwanted procedure, I'm guessing it's because you've got a job lined up in another field, since nursing employment will be over for ya.