Clinical Ethics Committee Case 16: A request from an accident and emergency department – should we give our patient a blood transfusion?

Abstract

9.30pm on a busy Tuesday night in the Emergency Department. Louise is a 29 year-old woman who has been admitted following a road traffic accident. She was driving her car on a single carriageway when her vehicle left the road and hit a tree. Her vehicle was extensively damaged and Louise had to be cut out of the wreckage. The accident has caused Louise to sustain severe injuries, which on initial assessment appear to include chest fracture, head injuries, cuts that have given rise to significant blood loss and two badly broken legs. Louise is currently unconscious. It is anticipated that Louise will require surgery early the following morning. During the course of this surgery it is anticipated that Louise will require at least four units of blood to be transfused. A senior member of the treatment team asks Rachel, a junior doctor, to begin making arrangements for the availability of blood for transfusion. However on her way from the area where Louise is being treated, Rachel is approached by the staff nurse. He asks her to stop and talk with a group of people who have arrived in the Department. They identify themselves as Louise’s friends and state that they are Jehovah’s Witnesses. They also tell Rachel that Louise is a Jehovah’s Witness and that they all worship together regularly. Louise’s friends state, adamantly, that Louise takes her faith very seriously and that she would certainly refuse a blood transfusion. They also state that Louise would still refuse a transfusion even if the result would be that she would die. Rachel is unsure whether to go ahead and organize the units of blood or whether she should further explore the information she has been given by Louise’s friends. While Rachel is talking with her friends, Louise regains consciousness and on assessment the team feel that even though she is very unwell, she is able to understand and retain information about what has happened to her and to use this information to consider the offer of a transfusion. Louise initially agrees to a transfusion, so Rachel quickly leaves the Department to go and get this organized. While she is away, Paul, one of Louise’s friends, spends some time talking with her. When Rachel returns, she is told that Louise has now changed her mind and is refusing a transfusion. It has also emerged that even though she is a committed Jehovah’s Witness, Louise has joined the faith only in the last year and has lost contact with her family. At this point, Rachel suggests to the medical team that she contact a member of the Hospital’s Clinical Ethics Committee via the Switchboard. We are approaching the ethics committee with the following questions in mind: 1. If Louise had not regained consciousness, to help us make a decision about transfusion, what additional information should we seek, from whom and how? 2. Again, if Louise hadn’t regained consciousness (and given her need for surgery), how should have we handled the friends’ claims about Louise’s faith? What should we have done and why?3. What if Louise had suffered an acute deterioration in her health that evening? What should we have done? What if the care team couldn’t agree about what to do? 4. The fact that Louise has changed her mind about a transfusion after speaking with a friend worries us. What should we do about this? How can we adequately explore the possibility of coercion or undue influence in the consent process, particularly in an Emergency Department? 5. What would constitute a valid advanced decision for this sort of situation?