Articles and Case Studies

Treatment Refusal

31 Jul 2008

by Ms Philippa Nash and Dr Andrew Miller

Consider this case. A thirty five year old patient was admitted to hospital early in the morning for a major orthopaedic procedure which it was anticipated would involve large volume blood loss.

Case history

He had been seen in the anaesthetic preoperative assessment clinic six weeks prior and had consented to general anaesthesia, invasive monitoring, epidural pain management and blood transfusion if required. This had been done in the presence of family members who acted as partial translators as English was his second language. He was not a suitable candidate for autologous predonation of blood. Once in the anaesthetic room adjacent to the operating theatre an intravenous line was inserted and preoxygenation commenced. He removed the mask and requested that he not be given any blood products during the procedure. Upon further discussion it transpired that he had two weeks prior become engaged to be married and converted to the Jehovah’s Witness faith. Due to the time required to explore the issues surrounding this change in consent and the non-emergency nature of the operation, the procedure was cancelled and a follow up appointment with an interpreter arranged.

Medico-legal issues

The legal position can be summarised as follows:

  1. Blood transfusions administered against the expressed wishes of a Jehovah’s Witness may constitute an assault, including blood transfusions which take place in an emergency, when it is known that the person is a Jehovah’s Witness and that they do not wish to receive a blood transfusion.
  2. Even in emergency and life-saving situations, blood transfusions should not be administered when the patient’s wishes to refuse treatment with respect to blood transfusions are known.
  3. Where the patient is competent to discuss the issues, a senior member of the health care team should:
  • Discuss the rationale/benefits regarding the proposed treatment.
  • Discuss the potential side effects/risks of the proposed treatment.
  • Discuss the potential risks of not receiving the proposed treatment.
  • Discuss the patient’s reasons for declining/refusing treatment, to determine whether alternative strategies which are acceptable to both the patient and clinic staff, are available. There may be instances where a Jehovah’s Witness patient will indicate (usually when there are no family members or members of the faith present) if it is necessary to preserve their life, that they will agree to receive blood products. A practitioner should keep any such consent by a patient in the strictest confidence as it is likely that the patient will not want family members or other members of the faith to know.
  1. In an emergency, where a person is unable to express their consent to medical treatment, a medical practitioner may provide treatment:
  • To save the patient’s life.
  • To prevent serious damage to the patient’s health.
  • To prevent suffering or continued suffering from significant pain or distress.

However, a medical practitioner cannot provide emergency treatment when they know that the patient does not wish to receive that treatment.Consent where a patient’s wishes are unknown can be sought from next of kin and guardians but practitioners should seek advice from hospital administrators or MDA National in these circumstances.
  1. There are laws that apply specifically to emergency treatment of children in similar circumstances. Doctors should seek advice if it is likely that the parents or guardian will not agree to a treatment that is viewed as essential by the medical staff, such as emergency blood transfusion. Generally the opinion of two medical practitioners is required in these circumstances.

Discussion

It is important for a practitioner not to impinge their own personal beliefs upon the patient’s care. The acceptance or refusal of blood or blood products or indeed any treatment is the competent patient’s decision.

MDA National can provide advice specific to the clinical circumstances if you find yourself in an analogous situation.

Philippa Nash LLB 
Manager, Claims and Advisory Services (Solicitor)

Dr Andrew J Miller MBBS LLB (Hons) FANZCA FACLM GAICD

Consent, Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Psychiatry, Radiology, Sports Medicine, Surgery, Physician, Geriatric Medicine, Cardiology, Plastic And Reconstructive Surgery, Radiation Oncology, Paediatrics, Independent Medical Assessor - IME
 

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