Question

A 76 year old man with a history of coronary artery disease, diabetes and hypertension was brought in by his wife with two days of lethargy, slurred speech and right arm weakness. On presentation, the patient was awake and intermittently involved in conversation. He was afebrile, with a pulse of 90 and blood pressure of 166/98 His exam was remarkable for dysarthria, orientation only to person, pinpoint pupils, left sided tongue deviation, 3/5 motor strength in the right upper extremity, 4/5 motor strength in the proximal right lower extremity and right sided hyperreflexia. A non- contrast head CT revealed an acute left thalamic hemorrhage with surrounding edema and midline shift. The patient was evaluated by neurosurgery, but given the location of the bleed, no surgery was indicated Platelet transfusion was recommended, as the patient had medication induced platelet dysfunction. The patient's wife refused platelet transfusion as the patient was a long-standing Jehovah's Witness. She had a copy of his Advanced Directives in which she was appointed the health care proxy and it was clearly outlined that he would not accept any blood product transfusion. An ethics consultation was requested Questions 1. From an ethical and legal standpoint how should a physician handle these situations? 2. If the patient can indicate that he wishes to accept platelets at this time, should his Advanced Directives be disregarded? 3. Would the situation be different if the patient were a minor and the parent's refused transfusion? Alana Choy-Shan PGY-3

Answer 1

1.From ethical and legal standpoint a Physician should inform to the patient and attenders regarding the complications of refusing platelet transfusion and the patients' health is in danger thereafter.Still if they refuse for the platelet transfusion then their decision is given importance.No force should be done for treatment.Its the autonomy of consumer.And the physician should respect their decision.But consent can be taken stating that they are refusing the treatment of platelet transfusion and will face any health consequence.

2.Treatment can be provided in terms of cancellation of the advanced directives directly by the patient ,if patient notifies attending physician or requesting nursing staff notify attending physician of such desire.

3.In case of minor child even on parents denial if the child gives consent for platelets transfusion or any treatment against parents decision then the treatment should be continued according to the International rights of children.