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Case Study -"Juana" (fictitious name) a 20-year-old, Black Hispanic female, 32 weeks pregnant, was brought to the emergency department (ED) in an ambulance by the paramedics. She arrived in the ED immobilized on a flat board with a hard cervical collar in place. Juana was the driver of a sedan involved in a single-vehicle collision. She stated she was driving at approximately 60 miles per hour on the highway and suddenly lost control of the vehicle and crashed into a light pole. She also stated her head hit the windshield and shattered the glass. She denied loss of consciousness. Upon her arrival in the ED, Juana was alert and oriented to person, place, and time and had a Glasgow Coma Scale of 15/15. Her initial complaints were lightheadedness, weakness, left shoulder pain, and severe abdominal cramping that started immediately following the car accident. She had a past medical history of sickle cell disease and no previous pregnancies. Her lungs were clear bilaterally. Juana's heart rate was 90 beats per minute (bpm), her respiratory rate was 28, and her initial blood pressure (BP) was 130/80, and fetal pulse rate was 90. Once the cervical spine films were taken and the flat board was removed, her BP reflected orthostatic changes of 100/60 and pulse of 120 bpm. Diagnosis and interventions
Juana was placed on a 100% nonrebreather mask. Peripheral intravenous lines were started bilaterally to replace fluid loss that was indicated by the change in vital signs. It was suspected that she was bleeding internally into her thoracic or abdominal cavity. Blood specimens were drawn and sent to the laboratory. A hemoglobin of 6 g/dl and hematocrit of 21% indicated internal bleeding. Ultrasound showed blood in the amniotic cavity and Doppler confirmed a fetal heart rate of 90 bpm indicating fetal distress. The patient was informed by the medical team of the critical nature of her condition.
The plan of care for her was an immediate blood transfusion and an emergency cesarean section. Matters became complicated when Juana informed the medical team that she was a Jehovah's Witness and refused the proposed plan of care. The physician then recommended the use of alternative blood products. Juana insisted that this was also against her religion and she refused the alternative treatments being offered. The medical team advised her that Jehovah's Witnesses could choose certain blood byproducts, such as albumin, cryoprecipitate, and globulin (Watchtower Bible and Tract Society, 2004).
According to Juana and her husband, both believed that if she accepted the blood transfusion or blood products she would no longer be a Jehovah's Witness and would be condemned to hell. The husband then presented the physician with Juana's blood card, created by the Watchtower Bible and Tract Society, the governing organization of Jehovah's Witnesses. The card stated her advance directives, including the prohibition of blood and blood products. Jehovas witness are taught to not accept any blood or blood products. They are instructed to expel and shun members who do accept blood or blood products. The Watchtower society explains that any members who do accept blood will be condemned to hell and that they should only accept the bood of Jesus. Because of this policy patients health care decision making is compromised.
Juana's condition worsened within 2 hours of admission to the ED. She went into labor and delivered a stillborn baby boy. She was immediately transferred to the intensive care unit where, despite continued aggressive attempts to stabilize her, she went into cardiac arrest and died. (de franka, Baptista, Brito, 2008)
This case study represents an ethical dilemma, which is defined as , the need to choose from among two or more morally acceptable courses of action, when one choice prevents selecting the other; or, the need to choose between equally unacceptable alternatives (Hamric, Spross, and Hanson, 2000). These decisions can yield results that can be negative or positive for the parties involved. In this case Juana chose to remain steadfast with her decision to refuse treatment so that she can be true to her religious beliefs. In this instance her choice resulted in death of her and her baby. If she had listened to the physcians and Interdisciplinary teams recommendations the outcome could have been different sparing her and her babies life but woud have the undesired effect of violating her religious principles. The physicians ethical dillema was that by respecting the patients autonomy and accommodating her religious beliefs, they were faced with circumventing their moral duty to provide profession care adhering to established standards. This case is a situation where Ethics and Law collide. Guido (2010) states:
the law recognizes the competent patients right to refuse therapy. The patient retains this right whether health care deliverers agree or disagree with the persons choice(Guido, 2010). Guido (2010) states, If there are overriding state interests, treatment may be mandated against a patients or parents wishes(p.4). For example, the Illinois Supreme Court case (Illinoise v. Brown, 1996) sided with a mothers decision to refuse blood transfusions even though they were severly needed for both the mother and the fetus to survive. In the healthcare field nurses use several different ethical principles daily in their practice, a guiding principle is the patientss right to autonomy rather than religious beliefs. Autonomy involves health care deliverers respect for patients rights to make decisions affecting care and treatment, even if the health care deliveres do not agree with the decisions made(Guido, 2010). The American Nursing Association code of ethics for nurses (2001) states, the Client (patient) have the right to make decisions for their health (example informed consent); to be given accurate information to make these informed decisions; to be assisted in making these decisions; to be given emotional support; and be able to accept, refuse, or terminate treatment without any coercion (p.1).
The case was reviewed by the ethics committee because of the ethical dillema at hand. The parties involved with this case were the woman, fetus, husband, physician and his interdisciplinary healthcare team(de franka, Baptista, Brito, 2008). In analyzing this ethical dilemma, the case fell under the ethical theory of virtue ethics. Using the autonomy model the committee anaylized the decision making process used in this case. Autonomy model facilitates decision making process for the competent patient (Guido, 2010). They identified the problem being the 32 week pregnant woman who was involved in a car accident was suspected to have internal bleeding by the ED physicians. The team advised the patient that the best mode of treatment was blood transfusions and an emergency cesarean section. The patient and her husband refused this option because of their religious beliefs and they provided written documentation stating that the patient would not accept blood or blood products. Because of this refusal of treatment both the patient and fetus died. The health care teams values were conflicted because the survival of the woman and her fetus was dependent upon receiving blood but the womans religious integrity would be at stake. The ethical principles involved were autonomy, nonmaleficence, justice,veracity and respect for others. The way the patients religious beliefs influenced her decision also needs to be taken into consideration. Juana was a competent patient who made the informed decision to refuse blood transfusions and a cesarian section. Using virtue ethics, the healthcare team respected her autonomy by honoring the patient and her husbands decision which is based upon her religous beliefs and values( de franka, Baptista, Brito, 2008).The health care providers used the principle of beneficence, which means their actions were promoting the good of the patient (Guido, 2010). They also used principle of nonmaleficence by not inflicting harm on the patient by honoring her wishes. Guido (2010) states the aspect of harm is different for individual patients. For this situation violating her religious values would be the harm. The health care providers also followed the priciple of veracity and respect by being truthful to the patient and allowing her to make an informed decision and respecting that decision. The ethics committee found that at this hospital there were no jehova witness protocols in place for dealing with this type of situation. So an option for resolution is to develop a protocol requiring patients who refuse blood or blood product transfusions to sign a waver that releases the hospital and caregivers from any legal responsibility, identification of jehovas witness early, completing advance directives for these patients, to monitor the hemoglobin and hematocrit levels closely, and to have a list of hospital affiliations that are well equipped for bloodless modalities of treatment. The Society for the Advancement of Blood Management has a database of these hospitals that provide blood conserving services in the United states, Canada, Chile, Krea, and south Africa(Society for the Advancement of Blood Management, 2008). Another resolution option from the health care providers perspective would be to give the patient blood products because when she was rapidly declining she most likely would not be competent at that point and in emergency situations without a advance directive and the patient being a full code the physicians and staff would need to do whatever possible to save her and her fetuss life. This resolution option would not work in this case because the husband would be her decision maker if she is not competent. That is why it is important for jehova witness to have their legal documents and advance directive on them at all times and have them easily accessible so that in an emergency situation the health care providers can honor their wishes. By honoring their wishes the health care providers would be using virtue ethics.
This dilemma is difficult because it is difficult to witness death when there are life saving measures that can be done and the patient is choosing to refuse the treatments. By honoring her wishes the healthcare team had to put their moral values to the side to respect her autonomy and deliver care that is appropriate to the established standards. When asked by the committee which option I would choose I said the option of allowing the patient to refuse treatment and beginning a protocol which removes legal ramifications from the hospital and their caregivers.(de franka, Baptista, Brito, 2008) By doing so the healthcare providers would be practicing beneficence and nonmalefcince without forcing their beliefs on what is the right thing to do. This protocol would be very beneficial in the healthcare settings because it would benefit not only the hospitals but also the healthcare providers and patients when these type of situations occur.