An unconscious 42-year-old man is brought to the emergency department by ambulance after sustaining a gunshot wound to the chest during an attempted robbery at a convenience store. He is bleeding profusely. The patient is minimally responsive to pain and is unable to provide any history. The ambulance record indicates that his initial blood pressure was 120/70 mm Hg, pulse was 95/min, and respirations were 16/min. The patient's current blood pressure is 70/40 mm Hg, pulse is 130/min, and respirations are 28/min. He has an open gunshot wound in the chest and an exit wound in the back. Intravenous fluids and vasopressors are started, and a blood transfusion is ordered. The patient's fiancé arrives and states that he should not receive a blood transfusion because he is a devout Jehovah's Witness. No evidence is found in the medical chart of advance directives or a living will documenting the patient's wishes, and examination of his belongings show no blood refusal card. Which of the following is the most appropriate next step in management of this patient?

Question

An unconscious 42-year-old man is brought to the emergency department by ambulance after sustaining a gunshot wound to the chest during an attempted robbery at a convenience store.  He is bleeding profusely.  The patient is minimally responsive to pain and is unable to provide any history.  The ambulance record indicates that his initial blood pressure was 120/70 mm Hg, pulse was 95/min, and respirations were 16/min.  The patient's current blood pressure is 70/40 mm Hg, pulse is 130/min, and respirations are 28/min.  He has an open gunshot wound in the chest and an exit wound in the back.  Intravenous fluids and vasopressors are started, and a blood transfusion is ordered.  The patient's fiancé arrives and states that he should not receive a blood transfusion because he is a devout Jehovah's Witness.  No evidence is found in the medical chart of advance directives or a living will documenting the patient's wishes, and examination of his belongings show no blood refusal card.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient is a presumed Jehovah's Witness who presents with hemorrhagic shock and is likely to benefit from a transfusion that could prevent exsanguination. Because the patient lacks decision-making capacity, providers should determine if he has completed an advance directive that can guide treatment decisions. Most Jehovah's Witnesses carry advance directive cards that explicitly document the individual's refusal of a blood transfusion. In the case of adult patients, courts have consistently supported the right to refuse blood on religious grounds. In this case, no advance directive card is provided and delay in treatment could place the patient in serious harm. The Health Care Consent Act has been applied to Jehovah's Witnesses to allow transfusion to preserve a patient's life in an emergency when no blood refusal card is present. The patient's fiancé is not a legal next of kin and cannot serve as a substituted decision-maker (Choice E). (Choice A) Case reports have shown some success in using high-dose erythropoietin, crystalloids, intravenous iron, and other products to address massive hemorrhage without a blood transfusion. These treatments could be discussed if the patient was conscious and refused a blood transfusion. (Choice B) Ethics committees provide advice if disagreements or ambiguity exist between health care providers and a patient/patient's family on decisions involving withholding or withdrawing life-sustaining treatments. This patient needs treatment quickly, with no time for discussion with the ethics committee. (Choice C) Court approval is not needed for a physician to proceed with emergency life-saving treatment for an unconscious or unresponsive patient. Educational objective: In the absence of an advance directive, a life-saving blood transfusion can be given to a Jehovah's Witness who lacks decision-making capacity. References: The contemporary approach to the care of Jehovah's witnesses. (http://www.ncbi.nlm.nih.gov/pubmed/18580506) Ethical principles--emergency medicine. (http://www.ncbi.nlm.nih.gov/pubmed/16877128) Operating one-handed: emergency treatment of Jehovah's Witnesses. (http://www.ncbi.nlm.nih.gov/pubmed/23337864)

An Unconscious 42-Year-Old Man Is Brought to the Emergency Department