This module discusses the legal and ethical considerations around the bloodless approach and identifies strategies that promote shared decision-making between healthcare providers and their patients.
These Continuing Education (CE) accredited introductory modules walk learners through the history of bloodless medicine and surgery (BMS); identify key factors that led to the growth of the bloodless approach; outline strategies that ensure patient safety and well-being; and discuss legal and ethical concerns related to BMS. The intended audience for these modules are healthcare providers and administrators throughout the world who are interested in learning about the care of patients who decline blood transfusion.
So far, we’ve seen how bloodless medicine came to be recognized as an effective approach to patient care and discussed strategies that clinicians have devised over the years to ensure that patients who decline blood receive quality care. Now let’s turn our focus to the legal and ethical considerations that come into play when practicing bloodless medicine and surgery.
Consider the following scenario: A Witness patient comes in with severe flank pain and blood in urine. You determine that he has renal carcinoma and needs a resection. He states that he refuses blood transfusion and presents a medical directive to that effect. What do you do?
Option 1: Refuse to treat the patient and take no further action.
Outcome: Refusing to take any action to help the patient receive treatment would delay appropriate care, possibly leading to harm or death.
Option 2: Agree to treat the patient with the plan of later persuading him to accept a blood transfusion if an emergent situation develops.
Outcome: Jehovah’s Witnesses refuse blood transfusions even during emergent situations. The use of shame or coercion to persuade the patient would be a violation of his right to self-determination, and misrepresentation of your plan of treatment would be a serious ethical breach.
Option 3: Refer the patient to another physician or hospital qualified to treat the patient using the tools and techniques of bloodless medicine and surgery.
Outcome: If you cannot conscientiously treat this patient without the use of transfusion or blood products, you can still work with him to find a qualified physician and, if necessary, promptly transfer him to a hospital that can provide treatment.
Option 4: Use the tools and techniques of bloodless medicine and surgery to treat the patient safely and effectively.
Outcome: Being willing and able to implement viable alternatives to blood transfusion allows you to respect this patient’s expressed wishes and provide optimal care.
Recap: Legal and Ethical Considerations
This scenario highlights crucial ethical—and legal—concerns that can arise at the intersection of the obligation of the physician and the conscience and rights of the patient. Let’s hear more about this from Mike Hofmann, director of the Bloodless Medicine and Surgery Program at MedStar Georgetown University Hospital and MedStar Franklin Square Medical Center.
Director, Bloodless Medicine and Surgery Program
MedStar Georgetown University Hospital and MedStar Franklin Square Medical Center
Probably going back to the 1990s, there was really a movement of patient rights. And it was a real seismic shift in the way patients had been treated in the past. And it continues to this day, it’s really accelerating: where the patient becomes the focus, as opposed to the physician and the hospital and their rights and privileges being the focus. So in the past it was a very paternalistic approach. The physician was always right, typically male, and the patient was expected to accede to their wishes.
But through law and court cases, more and more emphasis was placed on, “No, no, wait, it’s the patient’s body. That’s a fundamental right that cannot be abridged.” The physician has to recognize that his professional privilege is not on the same level—before the law or ethically—with the patient’s fundamental right to determine what will happen to their body. Really you want them to be involved in the decision-making process, as opposed to just being told, “This is what you need, this is what we’re going to do.” And so whether a bloodless patient or other patients, this is now the standard of care.
In the case of a minor, a child, the laws in the country give more leeway to physicians and hospitals. And especially difficult circumstances, if there are court orders involved, it’s very traumatic for parents—and the hospital and physicians alike. It’s not an easy process to go through. So to avoid that would be to the benefit of all involved. Avoiding it not by neglecting the needs of the child, but by researching alternatives—viable alternatives—that are being utilized by another doctor or another institution. And what we find is that the emotional aspect of this is what really will carry the day. In other words, the physician’s emotions rise because they’re dealing with a child. And that’s a natural response. The parents obviously are emotionally involved. And so there’s a heightened emotional sense.
Our experience is that if that can be reduced, if the anxiety can be reduced—the emotional atmosphere—then there’s a much better chance to look clinically at the situation. To look for options to treat the child and respect the parents’ wishes. And that’s been demonstrated that that’s a workable solution many times over.
Plan: Consent form
As Mike Hofmann mentioned, shared decision-making creates an atmosphere in which patients are equal partners in their own care. Now, what this looks like exactly may vary by location and culture, but there are some general steps that we can all take.
Work with the bloodless patient to prepare a plan in advance of their treatment. Presenting the patient with a consent form at the start of their treatment can facilitate a discussion of what their wishes are and what alternatives would be acceptable to them.
You’ll notice that the alternatives here have been categorized and broken down in significant detail, allowing patients to clearly indicate what they’re comfortable with. This is a great way to start the conversation about decisions you may face in the course of the patient’s treatment.
Plan: Medical directive
Often, Witness patients will carry a medical directive that expresses their wish for alternative treatment and that itemizes the alternatives they would personally accept. It also designates a healthcare agent who is familiar with the patient’s wishes and is authorized to speak on the patient’s behalf if the patient is incapacitated. This directive differs by state and adheres to local statutes, but like the consent form, it provides the opportunity to have a conversation with the patient about treatment options.
Reiterate and confirm
Follow up with the patient in the preoperative area on the day of surgery, and go through the consent form again so that they have an opportunity to confirm their accepted alternatives. This also helps ensure that all care team members are on the same page.
If the patient remains in the hospital after surgery, follow up to assess the need for any additional surgical interventions and transfusion alternatives.
Having a team experienced in bloodless medicine can help in the planning and execution of each of these stages and can provide patients a pathway to care from the moment they enter the hospital to the time they are discharged.
Legal and ethical strategies
Unsure of clinical options? Consult with qualified physician in hospital or professional network
Unable to treat patient? Refer patient to qualified physician and transfer to appropriate hospital/facility, if needed. Consult with the local Hospital Liaison Committee (HLC) when treating JW patients
Unsure of options? If you’re unsure of the clinical options available to you in treating a bloodless patient, consult with a qualified physician in your hospital or professional network. As we mentioned before, if you’re presented with a patient that you cannot conscientiously treat without the use of transfusion or blood products—or if you don’t have the skills or resources to treat them—you can still work with that patient to find a qualified physician and, if necessary, promptly transfer the patient to a hospital that can provide treatment. If you are treating a patient who is one of Jehovah’s Witnesses and require clinical assistance, you can contact the local Hospital Liaison Committee (HLC), who will be able to direct you to an appropriate resource.