N 512 Module 3 Assignment Powerpoint Presentation Case Scenario 2 A Jehovah’s Witness Patient On Page 77
N 512 Module 3 Assignment Powerpoint Presentation Case Scenario 2 A Jehovah’s Witness Patient On Page 77
The beliefs of Jehovah’s Witnesses are governedby their interpretation of scriptural laws and principles.In 1945, the Watchtower Society, the governing councilof the Jehovah’s Witnesses, prohibited the practice ofblood transfusions, specifically referencing 3 biblicalpassages: Genesis 9:3-4, Leviticus 17:10-16, and Acts15:28-29. These passages detail the sacredness ofblood and the prohibition of blood consumption, whichthe Jehovah’s Witnesses interpret as a ban tointravenous and oral routes. This blood ban includesallogenic whole blood, red blood cell concentrates,white blood cells, plasma, and platelets, as well as anyautologous blood that has been separated from thepatient’s body. Of note, many Jehovah’s Witnesses willaccept autologous transfusions if the tubing staysconnected to them, as in the case of cardiopulmonarybypass or hemodialysis.3,4However, changes in the blood ban guidelines areoutlined in an article entitled ‘‘Be Guided by the LivingGod’’ in a 2004 edition of The Watchtower.5 Thisarticle details what is unacceptable and what is for the‘‘Christian to decide.’’ The above treatments are stillbanned, but the administration of blood fractionatesfrom red cells, white cells, platelets, and plasma arepermissible and their use is up to the discretion of theindividual. These fractionates include albumin, recombinant human erythropoietin (rhEPO), immunoglobulins, and factor concentrates.5-7Treating a Jehovah’s Witness in situations thatpotentially require blood transfusion or products posesa unique medical challenge, involving the need toprovide optimal medical care through alternatives tothe standard of care while also respecting the patient’srights, values, and beliefs. It is crucial that physicianspresent and explain all options to Jehovah’s Witnesspatients.6,7 This paper discusses the ethical and legalconsiderations in addition to scientific and technicalchallenges for anesthesiologists and surgeons.
The doctrine of informed consent is to respectpersons by fully and accurately providing informationneeded to exercise their decision-making rights.Physicians must engage in the process of informedconsent with patients before undertaking any medicalintervention. Consequently, it is best to discuss withpatients the specifics of their blood transfusion refusalif possible.9,10 Patients have a moral and legal right torefuse proposed medical intervention, except when thepatient has diminished decision-making capacity or alegal intervention mandates treatment.11,12 Informedconsent protects both the patient and the physicianfrom the consequences of adhering to or refuting thepatient’s wishes. It is legally regarded as battery ifblood products are transfused after the documentedrefusal of blood products, despite whether the transfusion ultimately ensured the patient’s survival. Conversely, a physician will likely not be held liable ofmalpractice if morbidity or mortality result from nottransfusing in accordance with the Jehovah’s Witnesspatient’s wishes.13 However, in cases of emergent lifethreatening situations with no documented advancemedical directive, the physician is obligated to administer blood products if indicated.6,14The medical ethics are further complicated whenchildren of Jehovah’s Witnesses are involved. Inpediatrics, parents or guardians have the authorityto give consent by proxy, based on the assumptionthat their interests lie in safeguarding the child’swelfare. However, the physician’s legal and ethicalobligation ultimately lies with the child patient andnot the desires of the parents.15 The AmericanAcademy of Pediatrics recommends that the physician and other healthcare professionals recognizeand respect the importance of religion in personal,spiritual, and social lives of patients and ‘‘to avoidunnecessary polarization when conflict over religious practices arises.’’16 However, if religiousconvictions interfere with medical care that is likelyto prevent substantial harm and suffering or death,the physician should initiate legal action to overrideparental objections.16The power of the state to intervene is contained inthe legal concept of parens patriae that allows for theprotection of an individual who is not able to makedecisions in his or her own best interest. The firstcourt decision regarding the children of Jehovah’sWitness parents actually involved the sale of religiousliterature in violation of state child labor laws, but thiscase of Prince v Massachusetts17 has often been citedin subsequent medical-legal disputes.13 Justice WileyRutledge wrote in the majority opinion, ‘‘Parents maybe free to become martyrs themselves. But it doesnot follow they are free, in identical circumstances, tomake martyrs of their children before they havereached the age of full and legal discretion when theymake that choice for themselves.’’17 In a study of 50court publications concerning parent-physician disagreements over the care of children, court-mandatedmedical care was likely to succeed, especially whenthe case called for immediate intervention or whenparental objections were based on religion.18Mechanisms to resolve ethical conflicts includeadditional medical consultations with other involvedphysicians, surgeons, and anesthesiologists; shortterm counseling or psychiatric consultation for patientand family; case management conferences; consultation with individuals trained in clinical ethics or ahospital-based ethics committee; and the input ofhospital administration.13,19 Furthermore, because ofthe variability between individual beliefs, it is common for a Jehovah’s Witness patient to consult thecommunity elders or minister for help in reaching adecision regarding accepting any medical treatmentrelated to blood products.13,20Although blood components, autologous blood,and banked blood are generally unacceptable toJehovah’s Witnesses, providers should discuss anddocument specific acceptances and objections, thedegree of limitation, and changes to the plan forintraoperative management. It is best to consult eachJehovah’s Witness patient individually, wheneverpossible, to ascertain what treatments he or she willaccept to respect any advance directives.12,20 Documenting all discussions, conferences, objections,and acceptable interventions crystallizes the patient’swishes and provides legal documentation for theanesthesiologist. Anesthesiologists must be certainthey are capable of fulfilling the patient’s requests;otherwise, they should not agree to provide anesthesia.12,21 Anesthesiologists have the right to refuse toanesthetize an individual in an elective situation, andboth anesthesiologist and surgeon should providenonemergency care to the patient only if all partiescan agree on the approach to blood management.Medical, legal, and ethical issues associated withblood product administration to a Jehovah’s Witnesspatient have triggered continued efforts to reduceblood loss and thus blood transfusions. Numeroustechniques and interventions for the preoperative,Preanesthetic Assessment of the Jehovah’s Witness Patient62 The Ochsner Journalintraoperative, and postoperative stages have beendeveloped and used over time.
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