Emergency medical responders bring a 32-year-old woman, who is at 28 weeks gestation, to t… — USMLE Step 2 CK

Emergency medical responders bring a $32$ -year-old woman, who is at $28$ weeks gestation, to the emergency department after she was found wandering in traffic. The patient has a history of schizoaffective disorder and stopped taking her medications $3$ months ago. On arrival, she is actively vomiting large amounts of bright red blood. Vital signs are temperature $37.1^\circ\text{C}$ , pulse $135/\text{min}$ , respirations $24/\text{min}$ , and blood pressure $80/50\text{ mmHg}$ . She is extremely agitated, striking at the nursing staff, and screaming, "The doctors are vampires trying to steal my baby's soul!" She physically resists all attempts at medical intervention. The physician determines she lacks the capacity to make medical decisions due to acute psychosis.

The patient's sister, who is her legally appointed healthcare proxy, arrives at the emergency department. The sister provides a signed, notarized advance directive that the patient completed $5$ years ago during a period of psychiatric stability. The document explicitly states: "I refuse the administration of any blood products under all circumstances due to my religious convictions." The sister states, "I know what the document says, but she is pregnant and bleeding to death. As her proxy, I am authorizing you to give her the blood transfusion to save her and the baby."

Which of the following is the most appropriate next step in management?

Withhold the blood transfusion in accordance with the advance directive and resuscitate with intravenous crystalloids.Answer
B
Administer the blood transfusion because the designated healthcare proxy has provided legal consent to override the directive.
C
Administer the blood transfusion because the ethical obligation to protect the viable fetus supersedes maternal refusal.
D
Overrule the sister and breach confidentiality to contact the patient's estranged husband to act as the primary surrogate.
E
Transfer the patient to the psychiatric unit for involuntary commitment and behavioral stabilization prior to medical resuscitation.

Answer

Withhold the blood transfusion in accordance with the advance directive and resuscitate with intravenous crystalloids.

The correct answer involves respecting the patient's autonomy as documented in a valid advance directive. When a patient currently lacks capacity (in this case, due to acute psychosis and hemorrhagic shock), medical decisions must be guided by their previously stated wishes. A written advance directive created while the patient had capacity is the most authoritative representation of those wishes. Healthcare proxies exercise substituted judgment and are legally bound to follow the advance directive; they cannot override it, even in life-threatening emergencies. Furthermore, the ethical principle of bodily autonomy dictates that a pregnant woman's valid refusal of medical treatment must be upheld in the United States, even if it jeopardizes the life of a viable fetus. Therefore, the physician must honor the refusal of blood products and attempt to stabilize the patient using alternative methods, such as intravenous crystalloids.

Step-by-Step Solution

Assess the patient's current decision-making capacity.

The patient lacks capacity to refuse or consent to treatment due to acute psychosis and hemodynamic instability.

An actively psychotic patient who incorporates the medical staff into her delusions cannot demonstrate understanding of the risks and benefits of the proposed intervention.

Identify the highest-ranking legal source of decision-making.

A valid, notarized advance directive exists, which explicitly refuses blood products.

An advance directive created during a period of documented capacity serves as the most authoritative representation of the patient's autonomous wishes.

Evaluate the surrogate's authority to override the document.

The sister's consent is invalid for the blood transfusion.

A healthcare proxy is designated to implement the patient's wishes (substituted judgment). They do not have the legal authority to contradict a clear, specific, and valid advance directive.

Evaluate maternal-fetal ethical obligations in the context of treatment refusal.

The maternal refusal of care (via the advance directive) must be respected despite the viability of the fetus.

In the United States, a pregnant patient's right to bodily autonomy and refusal of medical treatment supersedes the state's interest in protecting the fetus.

Key Concept

Hierarchy of Surrogate Decision-Making and Maternal-Fetal Ethics

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic