Date: Wed, 29 May 2002 23:39:46 +0530

Subject: Refusal for Blood Transfusion

Friends,

I would solicit your views on this odd problem.

We had this case of subtotal amputation hand coming to us few days ago following an injury in a book binding unit. We were faced with a peculiar problem. The patient belonged to a religious sect which were totally against blood transfusion even in the face of life threatening situations. In this case the patient gave written consent for transfusion before the relatives arrived and the relatives though against transfusion did not stand against the patients decision. We manged to do the stabilisation, revascularisation and other work without transfusion though blood was available since the patient had a good Hb and remained stable.

A couple of months ago I had a case of multiple rib fractures with pneumothorax and the relatives from the same religious sect flatly refused any blood transfusion. Luckily there was no significant haemothorax and this again ended uneventfully. I remember a similar problem few years ago where for a trochanteric fracture transfusion was refused and surgery had to be deferred. I am sure everytime we may not get away without transfusion. My question is what are the moral, ethical and legal issues involved ? Where do we stand as treating surgeon if patient dies for want of blood transfusion? what is the experience of the list members in these issues world wide?

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.

Date: Wed, 29 May 2002 11:25:35 -0700

From: John Ruth

Seems to be a no win situation. If they refuse blood and you lose a lot you can be sued even if they sign indicating they refuse to receive it, even if it is life threatening. Seems like you have to respect their decision not to receive blood but you should not be legally responsible for blood loss which may be life threatening and correctable with a transfusion.

Date: Wed, 29 May 2002 18:44:57 +0000

From: b.meinhard

In the U. S. it is a legal issue for an adult, who in informed of the consequences of his decision, and who is mentally competent, to refuse a treatment recommendation even if it means his probable death.

bpm

Date: Wed, 29 May 2002 23:39:22 +0200

From: Victor de Ridder

In the the Netherlands it is also a legal issue for an adult, who is informed of the consequences of his decision, and who is mentally competent, older than 16 years (between 12 and 16 is a gray area), to refuse a treatment recommendation even if it means his probable death. So we treat and operate many Jehovah' s witnesses every year and do not give them blood. A minor part of the religeous group accepts blood of her/his own through the cellsaver system, a method we use in redo total hips, pelvic trauma etc.

Greetings,
Victor de Ridder

Date: Wed, 29 May 2002 20:39:48 -0400

From: Manuel Sotelo

Dear DR T I GEORGE

Do as your own country law requires. Specially in the States and in some states of Europe has become unlawful to do any transfusion against the patient wishes. There are some countries however where the opposite is true. If you don't give a medically needed transfusion, you will be indicted. The moral and religion issues will be hotly debated by any one in all fashions that you can't imagine. I once asked a innocent question about law and transfusions and ended insulted by a colleague in another list. Your country lawis what reallymatters andwhat you need to know. By the way, in Venezuela if you give a medical needed transfusion, even if the patient belongs to a religious sect that forbade it is lawful. The opposite, when you don't order a blood transfusion to a patient and the patient dies because of lack of care. The family can sue you. I do not have today a rigid stand point about this issue and I willtry to respect the wishes of any of my patients until I can encounter a legal problem.

Best wishes to all,
Manuel Sotelo.

Date: Wed, 29 May 2002 22:42:24 -0500

From: Gregory J Schmeling

I agree with Dr. Meinhard, an adult, who is able to give informed consent, may refuse a blood transfusion for religous or other reasons. But it is not so simple for the unconscious trauma patient. If the injured person gave another person medical power of attorney before the injury, the medical power of attorney may act for the unconscious person and refuse to consent for blood. If no medical power of attorney exists you have a difficult problem. A wife or family member technically may NOT give consent if they are not the medical power of attorney although we frequently ask them to. I think in that case we are trying to find out the unconscious patients pre-existing wishes. If you are unaware of the unconscious patients wishes you would be obligated to give the blood and would be protected by an implied consent principle ( what a resaonable person would have wanted in the same situation). I have been in the situation where the family says the unconscious patient does not want blood and then the patient wakes up and says no, I will take the blood. How do you figure that one out beforehand and what if they had died and you later find out that they would have taken the blood? Now consider the elective surgical patient. That is, they are not atrauma but would benefit from an operation with a potential for a large blood loss. What then? If they give informed consent and refuse any blood products are we morally bound to do the surgery if one feels that the risk of death is great? That sounds like it could turn into assisted suicide to me. I have struggled with that situation as well. In the trauma situation I think we are obligated to do the surgery and respect the request for no blood transfusion even if the patient risks death. I think our moral obligation is to explain the consequences of that decision to the patient or medical power of attorney and then proceed. Treatment techniques can be chosen in attempt to minimize blood loss. Perhaps, the injury could even be managed without surgery. Educating our populations before they get hurt and become unconscious to establish a medical power of attorney will help. The hardest thing to do is respect the choice of no blood transfusion even though we greatly disagree with the choice. Sorry for the many words, when you only respond to this list once in a while you tend to write too much. Best of luck.

Gregory J Schmeling, M.D.
Director, Division of Orthopaedic Trauma
Medical College of Wisconsin