http://www.mmhc.com/nhm/articles/NHM0101/hofmann.html
JW's relatives consent to give blood. (*Notice that "after the fact" she states she would have rather died.) [8>]
Case Report: The Use of an Ethics Committee Regarding the Case of an Elderly Female With Blood Loss After Hip Surgery
Mary T. Hofmann, MD, FACP, CMD, and
Donna Nahass, CRNP
History of Present Illness
Mrs. A is an 83-year-old African-American female resident of a nursing home who had fallen while using her walker in the hallway of the home, landing on her right side. She experienced subsequent right hip pain and an inability to stand. The etiology of the fall was unclear, as she did not recall how it happened. The fall was unwitnessed. She denied any prodromal symptoms of chest pain, shortness of breath, lightheadedness, or dizziness. She did not recall losing consciousness.
Past Medical History
Mrs. A’s past medical history was significant for Alzheimer’s disease, depression, Parkinson’s disease, osteoporosis, hypertension, type 2 diabetes mellitus, and Vitamin B12 deficiency. Her past surgical history was an unknown procedure to her right knee.
Social History
Mrs. A lives in a skilled nursing facility. She never smoked or drank, and is a retired teacher. Her functional history included needing moderate assistance in her activities of daily living; she was occasionally functionally incontinent of urine and ambulated with a walker.
Review of Systems
The review of systems was significant only for a 100-pound weight loss over the last 10 years.
Physical Exam
On physical exam, Mrs. A was a thin, frail, elderly African-American female lying in bed in no acute distress. Her vital signs were: temperature 99 F, pulse 100 beats/min, respiratory rate 16/min, BP: 170/92, HEENT: atraumatic, alopecia, sclerae anicteric, EOM’s intact, PERRLA, visual fields full, edentulous, no oral mucosal masses, neck supple, no JVD, no carotid bruits, thyroid not palpable and no lymphadenopathy.
Physical Exam
Lungs: CTA & P.
Breasts: Nipples everted, no palpable masses.
Cor: RRR, nl S1, S2, -S3, -S4, II/VI holosystolic murmur heard all over precordial area but best at apex without radiation.
Abd: BS+, soft, nontender, nondistended, no masses palpable, no hepatosplenomegaly, rectal exam revealed poor tone, stool was heme negative.
Ext: Right leg was shortened and externally rotated, no pedal edema, peripheral pulses were 2+b/l throughout.
Skin: Intact throughout.
Neuro: Awake alert and oriented x3. Folstein Mini-Mental Status Exam score was 19/27 with difficulties in memory recall and spelling world backwards even though she was able to spell it forwards. Reflexes were diminished throughout, +Babinski on the right, upper extremity strength 4/5 B/L; lower extremity strength 3/5 on the left, the right leg was limited due to pain. She had B/L cogwheeling.
Laboratory Data: PT/PTT 13.5/29.2, CBC: WBC 6.2, HGB 13.7, HCT 39.7, platelet count 146,000, chem-7: NA+141, K+ 3.8, C1 103, CO225, BUN 18, Cr 0.8, glucose 143 Pulse ox 97% room air.
CXR: Revealed a 5-cm solid right upper-lobe mass, no effusions, no interstitial edema, and no infiltrates. There was no previous CXR for comparison and there was no previous reports or patient/family knowledge of this mass.
EKG: Sinus tachycardia with 1°A-V block and LVH.
Hospital Course
The patient was admitted for management of a displaced right femoral neck fracture and a fall evaluation. Risks and benefits of surgical and nonsurgical managements were carefully discussed with Mrs. A and her family, which was comprised of two nieces; one niece was her durable power of attorney for health care. It was during this discussion that we discovered Mrs. A was a Jehovah’s Witness. She had opted for surgery with the hopes of regaining her ambulatory ability rather quickly, and she clearly stated that under no circumstances, even life-threatening, would she want any blood transfusions or blood products. She went on to state, with the orthopedic surgeons present, that if her life depended on a blood transfusion she would not want it, and if she should die as a result, her death would not be by the hands of the surgeons and/or anyone taking care of her.
Mrs. A was medically optimized for surgery using the AHA/ACC Task Force Perioperative Cardiovascular Evaluation tool.1 Mrs. A had some minor clinical predictors. Her functional capacity was deemed to be poor, but she declined noninvasive testing and was taken to the operating room. It was determined that the benefits outweighed the risks. Her chest x-ray, although troubling with a rather large mass present, was felt not to be an obstacle to surgery as she was asymptomatic and had been ventilating quite well. Workup of this mass would continue postoperatively and an intra-operative specimen of bone would be sent to pathology for analysis to rule out metastatic disease.
Mrs. A underwent surgery within 12 hours of her admission to the hospital. A bipolar hemi-arthroplasty was performed without complication. She tolerated the procedure well and was sent to the ICU, where she was extubated and carefully monitored for an overnight stay. Her postoperative medications included those mentioned at right: heparin subcutaneously every 12 hours had been discontinued and low-molecular-weight (LMWH) heparin 30 mg subcutaneously every 12 hours for DVT prophylaxis had been instituted along with ferrous sulfate 325 mg by mouth three times daily, and vancomycin 500 mg intravenously every 12 hours x3 doses for surgical prophylaxis.
The remainder of her hospital course was as follows. Postoperative day (POD) #1: the patient became lethargic, not responding to verbal stimuli but responding to tactile stimulation. Her vital signs revealed a BP/88-107/50-74, Temp. 100, P-86, RR 12. Her lungs were clear, EKG was without change, heart rate was regular without S3, abdomen was benign, her right hip surgical dressing was dry, and lower extremities were without edema. Combined intake and output for POD #1 was 3800/875 respectively.
Patient’s mental status was quite variable over the first three days postoperatively. Her level of alertness had improved but then by POD #3 had once again deteriorated with a decreased level of responsiveness. Daily, her hemoglobin and hematocrit had dropped as recorded below:
The source of blood loss was unclear. A rectal exam and daily stool hemoccults were negative. There was no oozing of blood at the surgical site, although the thigh had become edematous by POD #2. Serum haptoglobin and LDH were within normal limits.
Mrs. A received LMWH 30-mg subcutaneously every 12 hours POD #1 and POD #2, then it was discontinued. She wore sequential compression devices for DVT prophylaxis and was placed on erythropoietin 5000 units subcutaneously three days a week and ferrous sulfate 325 mg by mouth three times daily. POD #2 she was more responsive, awake, and alert. On several occasions, the house staff had asked Mrs. A, with her nieces present, if she wanted a blood transfusion, and repeatedly she refused.
On POD #3, Mrs. A’s hemoglobin had fallen to 5.6. As more staff were interfacing with the patient and family, repeated questioning continued regarding life and death issues surrounding blood transfusions. At this point she was unable to clearly restate her wishes refusing blood products. The patient’s nieces were at her bedside daily, asking their aunt whether or not she would want a transfusion. At one point, the patient’s power of attorney thought she had heard the patient say “yes.” The nieces became quite frightened over the potential loss of their aunt’s life as a result of refusing a blood transfusion. With encouragement from their mother not to have the death of their aunt rest on their shoulders, the nieces then decided to request a blood transfusion for their aunt. When the attending physician initially refused the request and tried to explain her reasons for doing so, the niece who was the power of attorney stated that she would sue the attending physician for not ordering the blood transfusion.
Some members of the nursing and medical staff were uncomfortable with the nieces’ decision. The staff felt that the family was no longer respecting the patient’s previously expressed wishes now that the patient was in a state of delirium and unable to speak on her own behalf. A medical ethics consult was called. The patient’s two nieces, the medical attending physician, the nurse practitioner, and an ethics committee convened. In view of the patient’s prior clearly stated wishes and repeated documentation in the medical chart that she would not accept any blood or blood products even if it was a matter of life or death, the ethics committee considered it binding to respect the patient’s wishes. The nieces, during the ethics discussion, came to recognize that the burden of the decision making was not theirs, that their aunt had previously made her decision.
Remainder of Hospital Course
Beginning POD #5, Mrs. A was given intravenous iron dextran each day for three days, and the ferrous sulfate was discontinued. She also received daily 10,000 units of erythropoietin subcutaneously. Etiology of the blood loss was still unclear. Her operative leg became progressively more edematous with only slight oozing of serosanguinous fluid at the operative site without any apparent fluid collections. By POD #7, Mrs. A’s mental status had returned to her baseline. She was awake and alert. Her vital signs were stable, and her physical examination was unremarkable. Blood draws were kept to a minimum, and by POD #8, a CBC revealed hemoglobin of 6.7 and a hematocrit of 19.3. Her platelet count was 435,000.
Mrs. A continued to improve physically and her hemoglobin continued to improve. Prior to discharge she expressed sincere gratitude to the medical nursing staff and her family for honoring her wishes and not giving her blood. She stated that she realized she could have died but reiterated that she would rather have died than receive a transfusion. She was discharged to her nursing home for continued physical therapy along with daily erythropoietin, and she continues to do well there at the present time.
Acknowledgment
The authors would like to thank Katherine Juiliano for her assistance with the preparation of this manuscript.
Reference
1. ACC/AHA Task Force Perioperative Cardiovascular Evaluation. Ann Intern Med 1997;127(4):309-328.
Dr. Hofmann is Director, Geriatric Medicine and the Muller Center for Senior Health at Abington Memorial Hospital, Abington, PA, and Medical Director, Foulkeways at Gwynedd, PA and Rydal Park, Rydal, PA. Ms. Nahass is Clinical Director, In-Patient Geriatric Assessment Team at the Medical College of Pennsylvania, Philadelphia, PA. Address for correspondence: Mary T. Hofmann, MD, The C. John Muller Center for Senior Health, Abington Memorial Hospital, 1200 Old York Rd, Abington, PA 19001-3788.
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Sally Nunn, RN, Faculty Associate at the Penn Center for Bioethics, and Clinical Ethics Consultant, Abington Memorial Hospital, provides an ethical perspective:
This case elicits a number of ethical issues that were considered in the resolution of the case of Mrs. A. First and foremost, autonomy, the constitutionally held right to self-determination, including the right to refuse any medical treatment, was a major factor. This patient had verbalized, over an extended period of time, a consistent and unwavering refusal of blood or blood products, knowing that this refusal could ultimately lead to her death. It should be noted that Jehovah’s Witnesses consider the administration of blood a “rape of their soul,” and many have stated that they would sue the physician who “saved” their physical life at the cost of their immortal soul. Second, was the patient, with a history of Alzheimer’s disease, competent? While this patient might not have met the legal standard of competency (not knowing the name of the President, for instance), she clearly understood the risks and consequences of her treatment options and therefore had equally valid medical decision-making capacity. Third, beneficence, weighing benefits and burdens in the consideration of hip surgery. Fourth, conflicting moral viewpoints. Although the family and providers would have chosen blood transfusions for themselves and the patient, their values cannot override the devoutly held beliefs of the patient. Are there instances in the clinical setting when families press the physician to disregard the oral or written directives of a patient? Yes! Does the physician sometimes comply with this possibly angry, frustrated, grieving, guilty, insistent, or agonized advocate? Yes! Should the provider abandon the fiduciary relationship with her/his patient? No! In virtually all cases, this dilemma can be resolved with adequate communication, time for processing, and, if desired and often helpful, consulting the ethics committee.
Lisa
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