Examkin

Soru

Zorluk: OrtaInformed Consent and Refusal

A 45-year-old man is brought to the emergency department by his wife for severe hematemesis. He has a history of peptic ulcer disease. On arrival, he is pale and diaphoretic. His blood pressure is 88/50 mm Hg, and his pulse is 120/min. He is alert, oriented to person, place, and time, and able to communicate clearly. The gastroenterologist recommends an emergent esophagogastroduodenoscopy with potential intervention and strongly advises a blood transfusion due to the severity of the bleeding. The patient consents to the procedure but explicitly refuses the blood transfusion, stating he is a devout Jehovah's Witness. The physician explains that without blood, he has a high risk of death. The patient reiterates his understanding of this risk and signs a refusal of consent form for the transfusion. During the procedure, the patient experiences massive hemorrhage, his blood pressure drops to 60/40 mm Hg, and he becomes unresponsive. The patient's wife, who does not share his religious beliefs, is immediately informed of his deterioration and tearfully demands that the medical team administer blood to save his life. Which of the following is the most appropriate next step in management?

  1. A
    Administer packed red blood cells under the emergency exception to informed consent
  2. B
    Administer packed red blood cells based on surrogate consent from the patient's wife
  3. Withhold the blood transfusion and continue resuscitation with crystalloids and vasopressorsCevap
  4. D
    Request an emergency court order to administer the blood transfusion
  5. E
    Obtain an expedited hospital ethics committee consultation

Cevap

Withhold the blood transfusion and continue resuscitation with crystalloids and vasopressors
The correct answer is to withhold the blood transfusion and proceed with alternative resuscitation methods. The ethical principle of autonomy and the legal doctrine of informed consent dictate that a competent adult has the right to refuse any medical treatment, including life-saving interventions. Because the patient made a clear, fully informed, and capacitated decision to refuse blood products just prior to losing consciousness, his directive remains binding. A surrogate decision-maker (like his wife) must act according to the patient's known wishes and cannot override an explicit refusal, regardless of her own beliefs or the severity of the clinical situation.

Adım Adım Çözüm

1
Assess the patient's capacity at the time the decision was made.
The patient was alert, oriented, and demonstrated understanding of the risks of refusing treatment.
Establishing that the patient had decision-making capacity makes his refusal legally and ethically binding.
2
Determine the legal standing of the wife's request.
The wife's request contradicts the patient's explicit, prior capacitated refusal.
Surrogates must use substituted judgment, meaning they must make the decision the patient would have made. They cannot override known wishes.
3
Select the appropriate clinical action.
Honor the patient's refusal of blood products and utilize alternative life-saving measures.
Respecting patient autonomy is paramount, and alternative stabilizing measures (crystalloids, vasopressors) should be maximized in accordance with his wishes.

Anahtar Kavram

A contemporaneous, fully informed refusal of life-saving treatment by a capacitated adult remains binding even if the patient subsequently loses decision-making capacity, and it cannot be overridden by a surrogate or the medical team.
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Konular

Informed Consent and Refusal

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