Cases & Commentaries

No Blood, Please

Commentary By Bryan A. Liang, MD, PhD, JD

The Case

A young woman, about 30 years of age, was injured
in an automobile collision. She was brought to the emergency
department (ED) via ambulance, where she was found to be suffering
internal bleeding with life threatening blood loss. After
examination, physicians advised her that without transfusion of one
to two units of blood within a very short time, she would die. The
patient refused the transfusion, stating that her religion forbids
it and that she understood the consequences. The ED staff deemed
her to be competent and was ready to comply with her wishes.

At about the same time that she was undergoing
examination, both her parents and her minister arrived. The parents
asserted that their daughter had recently converted to her new
faith only weeks before and therefore did not fully understand why
the religion forbids blood transfusion nor the consequences of her
decision. The minister, on the other hand, stated that the woman
converted to this religion with the full knowledge of its tenets
and was well aware of the consequences of her decision. He stated
that, at the time of her conversion, she swore an oath that she
would live by the tenets of the faith; that oath contained language
forbidding blood transfusions. As these discussions unfolded, the
woman lost consciousness. The ED staff reversed their previous
decision, and transfused two units of blood into the unconscious
woman. She was then taken to surgery.

The woman recovered from her injuries. She and
the minister of her church sued the hospital generally and ED staff
specifically. The judgment ruled in her favor, saying that the
hospital and ED staff violated her civil rights and interfered with
her ability to make her own decisions.

The Commentary

This case illustrates how the law can interface
with patient safety efforts, and highlights the need to pay close
attention to patients' wishes, regardless of the potential clinical
outcome.

As a primary matter, all patients have the
constitutional right to determine what shall and shall not be done
to them.(1)
This right extends to any treatment that may save the patient's
life. This includes blood transfusions, which are particularly
important in circumstances involving Jehovah's Witness
patients.(1,2)
Only in emergency circumstances where a patient lacks capacity to
consent can a provider transfuse blood without patient consent;
courts have allowed providers to perform such treatment on the
basis of assumed consent and public policy rationales.(1,3,4)
In circumstances involving children, courts have both allowed and
disallowed blood transfusion treatment recommendations when parents
object on religious grounds.(1)

In this case, the patient was in fact cogent and
of majority age; hence, her providers must follow her directives
regarding her care. Unfortunately, although providers here were
acting in good faith, any patient's care decisions are
constitutionally protected. Therefore, transfusion of blood to her
was in direct violation of her legal rights. In this situation, the
hospital, emergency room, and individual providers can be liable
for such actions, including actions for informed consent violation
and civil battery. This latter cause of action is extremely
important, since battery claims are amenable to punitive
damages.(1) In
the eyes of the law, it is irrelevant that the care provided did in
fact save the patient's life.

Patients' choices of allowing and refusing
treatment may present significant safety challenges. If patient
preferences conflict with provider knowledge of appropriate care,
these choices create additional sources of failure. Indeed, in this
case, the decision to transfuse was a medical error. Many
providers, such as emergency department, laboratory medicine, and
anesthesia staff, will likely encounter such circumstances. Clear
policies and procedures along with communication regarding protocol
requirements in these situations should be extant and part of
continuous safety training. It is not clear whether these
components existed, were available, or were known to providers
involved in this case. As a safety matter, root causes should be
assessed to create system improvement to reduce the likelihood or
mitigate potential recurrence of such an error. As a legal matter,
to avoid such lawsuits, protocols should expressly indicate that,
when faced with conflict between patient and provider preferences
for care, the specific objections of the patient, recommendations
of the provider, and competency assessments should be documented
clearly by the provider. If possible, it would be prudent to have
the patient indicate in his or her own words that he or she objects
to the proposed treatment and is refusing consent; the patient
should then sign that document. Moreover, at least one witness
other than the direct care provider should be present and sign the
patient's statement. In the event that no policy or procedure is
extant, providers should contact their general counsel to determine
what action(s) to take.

Hence, in this case, providers should not have
transfused the patient on both ethical and legal grounds. Policies,
procedures, and provider education should be implemented so that
occurrence of similar medical errors is minimized or potentially
mitigated by medical staff. This approach is consistent with
patient-centered care and respect for patient autonomy as well as
reduces the risk of litigation and associated damages that could be
associated with such actions.

Take-Home Points

  • Patients have the constitutional
    right to accept or refuse care.
  • In
    the eyes of the law, whether the care provided saved the patient's
    life is irrelevant.
  • If patient
    preferences and provider recommendations conflict, the objections,
    recommendations, and competency assessment should be explicitly and
    clearly documented.
  • Since patient preferences sometimes create safety
    challenges, clear policies and procedures should be in place
    regarding such situations, and related information should be
    included in patient safety education
    efforts.

Bryan A. Liang, MD, PhD, JD
Professor and Director
Institute of Health Law Studies
California Western School of Law
University of California San Diego School of Medicine

References

1. Liang BA. Informed consent. In: Liang BA.
Health Law & Policy. Boston, MA: Butterworth-Heinemann;
2000.

2. In the Matter of Melideo, 390 N.Y.S.2d 253
(N.Y.Sup.Ct. 1976).

3. John F. Kennedy Mem. Hosp. v. Heston, 279 A.2d
670 (N.J. 1971).

4. Hartman KM, Liang BA. Exceptions to informed
consent in emergency medicine. Hosp Physician.
1999;35:53-9.