Case study: an ethical dilemma involving a dying patient.
Article Type: Case study
Subject: Medical ethics (Case studies)
Medical ethics (Standards)
Duty of care (Law) (Standards)
Terminally ill persons (Religious aspects)
Terminally ill persons (Care and treatment)
Terminally ill persons (Case studies)
Author: Pacsi, Alsacia L.
Pub Date: 03/22/2008
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2008 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Spring-Summer, 2008 Source Volume: 39 Source Issue: 1
Topic: Event Code: 350 Product standards, safety, & recalls; 290 Public affairs
Accession Number: 184801424
Full Text: Abstract

Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life. This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and principles that apply to this situation.

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"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.

The beliefs of Jehovah's Witnesses stem from their interpretation of passages from the old testament of the Bible, which they believe is the inspired word of God (Watchtower, 2004). For example, according to the New World Translation of the Bible, blood symbolizes the life of the person or animal (Gen.9.36). Revelations (1.5) states, "The only appropriate use of blood is the sacrificial blood of Jesus." Another passage that Jehovah's Witnesses emphasize declares, "And whatsoever man there is among you, that eateth any manner of blood, I will even set my face against that soul that eats blood, and will cut him off from among his people" (Lev.7.10-14).

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.

The ethical dilemma

This case presents an ethical dilemma, a situation which arises when one must choose between mutually exclusive alternatives (Beauchamp & Walters, 2003). Decisions may have results that are desirable in some respects and undesirable in others. In Juana's case, her decision to refuse the blood transfusion had the desired outcome of allowing her to remain true to her religious beliefs. However, her choice also resulted in her death. If she had followed the recommendation of the physicians and the team, the desirable outcome would have been possible survival but would have had the undesired effect of violating her religious principles. The major ethical dilemma was that by honoring the patient's autonomy and religious beliefs, the physicians and interdisciplinary team were faced with compromising their moral duty to administer professional care in accordance with established standards (Chua & Tham, 2006). A brief review of the literature of Nursing Collection II: Lippincott Nursing Journals (from Ovid) and CINAHL databases for the past 5 years found no evidence to support best practice for a Jehovah's Witness who is pregnant and has experienced blunt trauma.

Healthcare providers faced with this situation have sometimes attempted to obtain court orders that would overrule the patient's decision and result in her submitting to recommended medical treatment. For example, the Illinois Supreme Court (Illinois v. Brown, 1996) upheld a mother's decision to refuse blood transfusions even though they were vital for both the mother's and fetus' survival. The Patient's Bill of Rights states that the healthcare providers' responsibility is to give patients accurate information and that patients must consent to treatment (New York State Department of Health, 2008). This is consistent with the Federal government's recommendations to create guidelines that assure healthcare quality and to reaffirm the critical role consumers play in safeguarding their own health, (United States Department of Health and Human Services, 1999).

Nursing practice is governed by the patient's right to autonomy rather than her religious beliefs (Levy, 1999). The first item in the American Nurses Association (ANA) Code for Nurses with Interpretative Statements (2001) addresses respect for human dignity:

"Truth telling and the process of reaching informed choice underlie the exercise of self-determination, which is basic to respect for person ... Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgments; to be assisted with weighing the benefits and burdens of options in their treatment; to accept, refuse, or terminate treatment without coercion; and to be given necessary emotional support" (p. 1).

However, it is difficult to witness death based on a person's decision to forgo care when medical options to sustain life are available. Treating this type of patient becomes particularly challenging when it involves two lives.

Virtue ethics

To analyze this ethical dilemma, the principles of Western medicine and the religious beliefs of Jehovah's Witnesses were examined. The questions that surfaced were (a) how would the application of virtue ethics provide insight into Juana's situation, (b) what were the ethical principles in conflict, and (c) why was it an issue to administer a blood transfusion to Juana in an emergency situation.

Volbrecht's framework for ethical analysis was utilized to address the clinical dilemma and the questions listed above. Virtue ethics was the primary theory employed prior to the 17th century. This theory centers on shared familial and cultural histories and religious traditions and acknowledges the community's ability to identify, interpret, prioritize, and adjust to moral considerations within a particular context (Volbrecht, 2002). The following is an exposition of this case according to virtue ethics.

Virtue ethics focuses on what is morally correct from the patient's viewpoint and centers on the patient's autonomy. Actions and character are intertwined, and the ability to act morally is contingent on one's moral character and integrity. Virtue ethics focuses on the context of the situation (Volbrecht, 2002). Ethical analysis of virtue ethics entails (a) identifying the problem, (b) analyzing context, (c) exploring options, (d) applying the decision process, and (e) implementing the plan and evaluating results (Volbrecht, 2002).

Identifying the problem

Juana, a 20-year-old Hispanic woman, 32 weeks pregnant, was involved in a car accident. Internal bleeding to the thoracic or abdominal cavity was suspected. The stakeholders were the woman, her husband, the fetus, and the interdisciplinary healthcare team. The team thought the best method of treatment for this patient was to administer a blood transfusion and perform an emergency cesarean section. Both the patient and her husband refused this option because of their religious beliefs and provided written documentation indicating that the patient would not accept blood or blood products. The value issues were the physical survival of the woman and her fetus versus the woman's religious integrity.

Analyzing context

To understand the decision-making process in this case, one must consider the ethical principles of autonomy, beneficence, nonmaleficence, justice, compassion, and respect. The patient's religious beliefs and how they influenced her decision must also be taken into consideration. Gardiner (2003) confirms that the ethical principles mentioned above influence one's choices. In Juana's case, the healthcare team suspected she was experiencing internal bleeding and that she and the fetus were in physiological distress. Juana's decision to reject the proposed treatment was based on her stated religious beliefs.

The contextual factors of this case centered on the patient's religious beliefs. The patient stated she would "rather be embraced in the hollow bosom of Jehovah than to be condemned for all eternity," if she should receive a blood transfusion. Nurses draw from the code of ethics to reflect upon and understand the person's perspective, and to honor her wishes. "The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problem" (ANA, 2001, p.1). To respect the patient's decision and honor her dignity, supportive care was provided to the patient in an effort to save her life, while at the same time respecting her wishes. The ANA Code of Ethics supports the point of view that healthcare providers should respect patients' wishes and decisions despite their own personal beliefs (ANA, 2001).

Applying an ethical decision process

Looking through the lens of virtue ethics, the caregivers focused on Juana's autonomy and her right to choose what she perceived best in spite of the possible outcomes. Juana was a competent, pregnant woman who made informed decisions not to receive blood transfusions or a caesarean section. Based on virtue ethics, the healthcare providers respected the patient's autonomy by reflecting on and honoring the decision of the patient and her husband based on her religious values and beliefs. The healthcare providers also drew on the principle of beneficence, which centers on promoting the well-being of others. In this case, the well-being was not physiological but spiritually oriented. The principle of nonmaleficence was also employed by not intentionally inflicting harm on the patient and honoring her wishes. Violation of a client's deeply held beliefs is a form of doing harm. (Leonard & Plotnikoff, 2000). They also drew from the principles of veracity and respect, which entail being truthful to the patient and allowing her to make an informed decision (Volbrecht, 2002). The nursing virtues of compassion, moral courage, and self-reliance also contribute to an understanding of this situation.

Evaluating results

At the time this clinical situation presented itself there were no specific guidelines in the institution for dealing with the dilemma presented by this case. However, there are guidelines for Jehovah's Witnesses specifically geared to early identification and management of gynecological patients. For example, in Australasia, there are specific guidelines for treating pregnant women that focus on stabilizing the patient by using traditional and new treatment modalities to meet patient needs, particularly for Jehovah's Witnesses or other patients who decline blood transfusions (Women's Hospitals Australasia, 2005). For antepartum patients, the guidelines focus on early identification of Jehovah's Witnesses during prenatal visits, as well as placing these patients on a high risk protocol, including maintenance of high hemoglobin and hematocrit levels, having advance directives completed, and establishing affiliations with other hospitals that are well-equipped and staffed to meet these patients' needs (Women's Hospitals Australasia, 2005). The Hartford Hospital in Connecticut has a similar program and also performs bloodless procedures on patients who are Jehovah's Witnesses (Miller, 1996).

As a result of Juana's case being reviewed by the ethics committee post-mortem, a risk-management protocol was developed requiring patients who refuse blood transfusions to sign a waiver that removes the legal responsibility for the decision from the hospital and caregivers. To support this type of protocol, the Society for the Advancement of Blood Management maintains a database of hospitals that provide blood-conserving services in the United States as well as in Canada, Chile, Korea, and South Africa (Society for the Advancement of Blood Management, 2008).

The problem, however, in an emergency situation is that it may not be possible to get the patient to a participating hospital. The Watchtower Bible and Tract Society (2004) recommends that advance directives and other legal papers be in place should an emergency arise. These documents should be easily accessible so that healthcare providers can honor the patient's directives. In so doing, they will be applying the theory of virtue ethics and, therefore, respect the patient's wishes (Macklin, 2003). Healthcare providers should practice beneficence and non-maleficence without imposing their beliefs as to the right thing to do. More explicit and universal guidelines would benefit both patients and providers when faced with similar ethical dilemmas.

Conclusion

In nursing practice, cases of patients refusing blood transfusions or other interventions are becoming more common. Therefore, content regarding ethical issues, such as Juana's case, needs to be integrated into nursing curricula and the clinical arena. Nursing educators who incorporate bioethics into critical thinking in clinical decision making situations can prepare novice and experienced nurses to handle complex ethical dilemmas, such as described in this paper. The learning process may be facilitated through integrating lectures with case studies and utilizing patient simulators to further enhance the learning process (Larew et al., 2006). These teaching approaches would provide the opportunity to expose nurses to scenarios of acute patients where they can intervene in a safe environment, which in turn would decrease their anxiety and promote learning. Nurse educators can further facilitate the learning process by providing clinical experiences with diverse patient populations in a variety of settings followed by discussion of actual clinical experiences, ethical issues, and debriefing (Larew et al., 2006).

Nursing faculty have an ethical responsibility to prepare competent nurses and facilitate continuing education that will help nurses recognize ethical dilemmas in practice and apply ethical principles in trying to resolve them. The focus in practice, education, and research must be on providing care that respects patients' cultural beliefs and autonomy. Nursing educators should place equal emphasis on ethics in order to provide the best holistic care possible. To do anything else is a disservice both to the profession and to our patients.

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Alsacia L. Pacsi, MS, RN, FNP, CEN, CCRN

Alsacia L. Pacsi is a nursing lecturer at Lehman College, City University of New York in Bronx, NY. She specializes in emergency and critical care nursing and is a doctoral nursing science student at the City University of New York Graduate Center. This article was inspired by a course assignment by Vidette Todaro-Franceschi, PhD, RN.
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