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Difficulty: MediumInformed Consent and Refusal

A 54-year-old man is brought to the emergency department with a massive upper gastrointestinal hemorrhage. His blood pressure is 85/50 mm Hg, and his heart rate is 120/min. His hemoglobin is 6.2 g/dL. The physician recommends an urgent blood transfusion, aggressive fluid resuscitation, and an emergent upper endoscopy. The patient is alert, oriented to person, place, and time, and communicates his wishes clearly. He states that he is a Jehovah's Witness and adamantly refuses the blood transfusion, although he consents to the endoscopy and the administration of intravenous crystalloids. He demonstrates a clear understanding that refusing the blood transfusion will likely result in his death. His wife, who is not a Jehovah's Witness, is at the bedside and pleads with the physician to administer the blood, stating, "He is just confused from losing so much blood. Please do whatever it takes to save him." The patient calmly reiterates his refusal. Which of the following is the most appropriate next step in management?

  1. Withhold the blood transfusion, administer intravenous crystalloids, and proceed with the endoscopyAnswer
  2. B
    Administer the blood transfusion based on the wife's substituted judgment as his next of kin
  3. C
    Delay the endoscopy and fluid resuscitation until an urgent ethics committee consultation can be completed
  4. D
    Request an emergency judicial review to determine the patient's legal competence to refuse life-saving care
  5. E
    Discharge the patient from the emergency department immediately because he is refusing the standard of care

Answer

The physician should respect the patient's autonomy by withholding the blood transfusion but proceeding with the treatments the patient has consented to, including intravenous crystalloids and endoscopy.
The principle of patient autonomy dictates that an adult with intact clinical decision-making capacity has the right to accept or refuse any medical intervention, including life-saving treatments like blood transfusions. To have capacity, a patient must be able to understand their condition, the risks and benefits of proposed treatments, and the consequences of refusing treatment, and must be able to communicate a clear choice. This patient clearly demonstrates capacity by acknowledging that his refusal may lead to death. Furthermore, a patient may selectively consent to certain procedures (endoscopy, IV fluids) while refusing others (blood). The physician is legally and ethically obligated to respect this partial refusal and provide the best possible care within the parameters set by the patient.

Step-by-Step Solution

1
Assess the patient's decision-making capacity.
The patient is alert, oriented, and clearly articulates an understanding of his condition, the proposed treatments, and the fatal consequences of refusing the blood transfusion.
Capacity must be established before accepting a patient's refusal of life-saving medical treatment.
2
Evaluate the wife's request to override the patient's refusal.
The wife's request cannot be honored.
The legal hierarchy of surrogate decision-makers is only invoked when a patient lacks decision-making capacity. A competent patient's wishes always supersede a family member's wishes.
3
Determine the appropriate management plan based on the accepted and refused treatments.
Proceed with fluids and endoscopy; withhold blood products.
Patients have the right to partially refuse care. The physician must provide the standard of care for the interventions the patient has accepted while respecting the limits set by the patient.

Key Concept

Competent adults have the right to refuse life-saving medical treatment, and their autonomous decisions supersede the wishes of surrogate decision-makers.
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Topics

Informed Consent and Refusal

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