Bioethics Discussion Blog: Another Ethical Dilemma: To Transfuse or Not Transfuse But Is That the Bloody Question?

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Friday, June 19, 2009

Another Ethical Dilemma: To Transfuse or Not Transfuse But Is That the Bloody Question?



WK was a 14 year old male and involved in a motor vehicle accident and was brought to the nearest community trauma center. The patient’s mother also involved sustained only minor injuries and was transferred to the same trauma center. WK sustained an open femur fracture with significant intra-pelvic trauma resulting in bowel injury and hemorrhage. When the trauma surgeon informed the mother that the seriousness of the boy’s injury would require blood transfusion in order to save his life, the mother refused to consider this option as it was not compatible with their faith. The trauma surgeon emphasized to the mother the severity of the boy’s condition and explained that the alternative treatments would not be sufficient. However the mother was adamant and continued to deny permission for transfusion. Operative auto-transfusion was also discussed with the mother but also not allowed.

Despite the lack of consent for blood product transfusion, the surgeon took the boy to the operating room. At the time of the operation the patient’s blood pressure was low because of the bleeding and trauma but conscious and alert. He understood he was going to undergo an emergency surgery. He was also made aware of the surgeon’s opinion that blood product transfusions were a necessity for his survival. But in addition, he was also made aware of his mother’s refusal to consent for these transfusions. On the ride to the operating room, in the elevator, the patient asked to be given whatever blood products were necessary to save his life. The surgeon documented the conversation with the patient’s own words “do whatever it takes for me to make it “. The patient also requested the surgeon to keep his transfusion record confidential and not disclose it to his mother. The patient had significant intra-pelvic hemorrhage and was given multiple intra operative transfusions. His intra-pelvic injuries and fractures were ultimately repaired and the bleeding stopped. Postoperatively his blood pressure was normalized and stable. He made a full recovery and was discharged. At the patient’s request, the mother was never notified of the patient’s transfusions. (Or did the mother finally find out from the hospital bills?)

So here are the issues that an ethics committee might have to discuss, but of course in retrospect:

Did the mother have the final decision-making capability?

To what extent can a 14 year old, who had the mental capacity of a 14 year old, make his own medical decisions?

Should the surgeon have honored the mother’s request over that of her son?

Should there have been disclosure by the surgeon of the transfusion to the mother?

What would happen if the patient, having received the transfusions, suffered a severe transfusion reaction or developed hepatitis or AIDS? Was the surgeon to blame?

Well, if you were a member of the ethics committee, how would you answer these questions? ..Maurice.

Graphic: Blood drop image via Google Image then concocted by me using ArtRage and Picasa3.

6 Comments:

At Thursday, June 25, 2009 10:33:00 AM, Anonymous Anonymous said...

The doctor made a note. Good practice.

Let's put it this way. Would we be looking at this 14 year old in the same way if he'd killed someone. I'm from the UK and the age of criminal responsibility is 10. If you are responisible for the crime and do the time then surely you are responsible for the choices you want to make on you future health and well being.

I watched a very moving programme once about sick children. One child had terminal cancer. Let's be straight about this chemo was tough for her and only prolonged life. Her mother decided to speak for her in front of the camera but she was adamant that the decision to stop chemo was her child's wish. She said all her child wanted to do was run through a forest before she died and she wanted to honour this wish before her child grew to weak to do so. This little girl was 8. I learn't a lot from that child.

Children do have patient rights.

 
At Monday, July 13, 2009 3:38:00 PM, Blogger Nicholas said...

Age of consent is tricky, no matter which ethical topic is being discussed. As a 18 year + veteran of type 1 diabetes, as soon as I had an opinion about my health care, I was involved with the decision-making process. While I didn't face immediate decisions regarding life and death, my hour to hour self-care would either improve and prolong my life, or negatively affect it. Education, even at the level of development, is most crucial, and each decision is individual. I hope parents are not always allowed to make such decisions for their children, and I hope that medical professionals understand the difference between a child wanting a nose job for cosmetic reasons, and a child that needs blood in order to survive a surgery.

-NG

 
At Monday, July 13, 2009 5:58:00 PM, Blogger Maurice Bernstein, M.D. said...

Nicholas, I think your personal responsibilities dealing with your chronic illness beginning at an early age provides a litmus test regarding the child's capacity to understand their illness, be responsible and make independent decisions regarding that illness. Evaluation of the child's responses to this illness may then provide guidance to parents and doctors regarding decisions made by the child to other medical situations. Unfortunately most children face only minor transient illnesses (which also might be looked upon as fortunate) which may not provide as much guidance to parents and doctors as yours.

Thanks for providing an example of how one could evaluate capacity in a minor. ..Maurice.

 
At Monday, July 20, 2009 8:59:00 PM, Anonymous Anonymous said...

I am sure to get flack over my answer... To be sure the kid is old enough to understand what death is.. and on that basis alone his wishes needed to be honored.
What I may get flamed over is.. it is not death from the loss of blood that I view as the worst.. A stroke and surviving in a bad way would be soooo much worse... Do doctors ever tell anyone of the other possiblities besides death?
leemac

 
At Monday, July 20, 2009 9:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Leemac, part of truly informed consent is disclosing to the patient the spectrum of possibilities which could occur if the patient accepts treatment or rejects treatment. Some treatments may be life-saving (prevent actual death) and yet not return the patient to a quality of life which the patient would desire. Some treatments may cause complications which would have not occurred without the treatment. Finally, a life-saving treatment may not be a transient treatment but the patient may require the treatment on a permanent basis to stay alive along with all the burdens of that treatment. An example would be treating a quadriplegic with ventilator respiration. Informing the patient all of this makes consent truly informed. ..Maurice.

 
At Monday, July 20, 2009 10:53:00 PM, Anonymous Anonymous said...

OK I accept that , Dr Bernstein. It just seems that most all that is discussed is just death.. when , kinda like your quadriplegic on a respirator, it is a matter of quality of life.. I understand that in the case of the boy so many things could go wrong.. contaminated blood among them... I more would hope that a doctor would tell a parent more than just that the child might die. At the risk of coming off as a hypocrite, I do not want blood at any time for any reason. I do this because I am at an age where the law and a physician would be able to judge my quality of life and more quickly than with a younger person withdraw life support..Even then I know that my thoughts on quality of life are different than most doctors.. but hope that my living will will be given more than a cursory attention and respect.
If a treatment had tooo great a risk of leaving a child in a bad way.. and low quality of life (hey some people want to live even if they have to be respirated, ventilated and put on heart machines. they want to be kept alive at all costs and no matter what) But a 14 year old is so young, he should be given every best chance to have a life.. If I were ever to be called on a jury to hear some case with what a doctor did (especially if the child asked)...He/she would not need to fear how I would vote.. I would also do it if the patient were 114. If anyone asks a doctor for a chance to live.. and the doctor can give them that chance..he/she should.
We offended teh nurses in CICU over my mom.. we insited she be woke up (she was on propofol or something like it) so she could tell the cardiac surgeon what she wanted instead of us just saying ok. The surgeon was cool with it.. even he said some folks want to go ahead.. others are tired and ready to die (His exact words)
So to with hold the treatment a boy asked for would have to come from a certain knowledge that one or more of the bad side effects or consequences was going to only have the child exist with great suffering.. boy I am glad I am not a doctor.. I do not know how I could tell a kid that..
Not that a doctor would do it.. but it would be far kinder to not tell the kid, but let him/her slip away during surgery.. just my mussings Dr. B.. I know that ethics and the law forbid it..
leemac

 

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