Witnessing death, preserving life: an ethical dilemma (hypothetical case).

Harvey Charles, a 51-year-old white man, had several episodes of chest pain and was referred to a cardiologist. Before cardiac catheterization, Mr Charles stated that he was a member of the Jehovah’s Witness faith and that he would not allow any transfusion of blood or blood products, and would not accept autotransfusion. He signed a specific directive for refusal of blood products. Catheterization revealed coronary artery obstructions that were not amenable to catheter treatment, and the patient was referred to John Smith, MD, a respected cardiac surgeon. The patient told the surgeon of his Jehovah’s Witness faith and his requirement that a blood transfusion not be given, signing a document declaring his refusal of blood transfusions and absolving the surgeon and hospital of all liability in case lack of transfusion led to serious complication or death. Because the patient and his wife of 30 years had planned a trip long ago to visit their grandchildren in another state, and because the operation was not urgent, it was scheduled for 2 months later. Preoperatively, the patient repeated his desire not to have blood transfusions, and signed the refusal document again. Doctor Smith agreed to withhold blood, even in the face of death. The procedure was uneventful, but 8 hours after the patient’s return to the intensive care unit, increased drainage of blood was noted in the chest tubes. Because of unavailability of blood, early reoperation was advised, and the patient agreed, restating his refusal of blood transfusion. Bleeding was moderately well controlled by the reoperation, but continued for the next few hours, slowing considerably by the next morning. After the second operation, Mr Charles failed to awaken fully from anesthesia. Two days after the second operation, the patient had signs of a stroke: semicomatose with right-sided weakness. At that time, Dr Smith noted that Mr Charles’ hemoglobin was 3.5 g/dL and hematocrit was 11%. He feared that low oxygen carrying capacity threatened imminently to worsen the stroke and perhaps lead to major myocardial infarction, with a substantial risk of death. Doctor Smith believed the clinical situation had changed dramatically since his last conversation with Mr Charles. He knew that patients sometimes change their minds regarding treatment refusals when faced with serious consequences, so, in keeping with his usual practice, he wanted to offer the patient the option of blood transfusion again, now that death seemed imminent. The patient, however, was incapacitated by his stroke, so could not make a decision on a final offer of blood. Rather than simply allow the patient to die without making a final offer of a transfusion, Dr Smith talked with Mr Charles’ devoted wife, who had been fully informed of the events since the operation. She was his legal surrogate decision maker, and was herself a Jehovah’s Witness. She initially refused the transfusion. The surgeon suggested she visit with her husband. After sitting for 30 minutes with the semicomatose patient, however, she asked Dr Smith to transfuse the needed blood, having come to believe that her husband might have changed his mind. Three units of packed cells were given, and the patient’s hemodynamics and clinical condition showed immediate improvement. Mr Charles’ neurologic deficit gradually cleared during the next few days, and he was discharged from the hospital 2 weeks after the operation. Six months later, the patient obtained a copy of his hospital record to deal with an insurance dispute, and learned that he had received blood transfusions. He expressed anger at his wife for giving permission for the transfusions, and was overcome with a wave of what he described as guilt and shame. He had crying episodes intermittently during the next few weeks. During that time, he was able to forgive his wife for what he considered to be her misjudgment, but continued to feel anger and outrage at Dr Smith for having broken what Mr Charles had taken to be his solemn promise not to give a blood transfusion. Address reprint requests to Dr Sade, Department of Surgery, 96 Jonathan Lucas St, Suite 409, PO Box 250612, Charleston, SC 29425; e-mail: sader@musc.edu.