This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.
The nurse has just found a card in Mrs. Montecino's purse identifying her as a Jehovah's Witness and stating her wish not to be given a blood transfusion under any circumstances.
You are about to see Mrs. Montecino's daughter, Annette Beaulieu. She has just arrived at the Emergency Department and urgently wants to talk to you about her mother.
CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^
YES NO The Candidate:
1. explains the seriousness of patient's
condition and what has been done medically:
e.g. patient is unconscious, losing blood,
suffering incipient shock, given intravenous
saline.
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2. ascertains if there are other family members
who should be involved in decision making
and/or who is the appropriate decision maker
for the patient.
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3. notes there is no date and/or no witness on
patient's Jehovah's Witness card.
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4. asks if daughter has discussed the issue (of
NO BLOOD) with mother.
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5. ascertains whether patient still believes in
Jehovah's Witness teachings.
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6. ascertains whether mother would still choose
"no blood" knowing it could mean her death.
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7. ascertains that daughter understands
seriousness of patient's condition and
consequences of not transfusing (i.e. mother
will die without blood transfusion).
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8. states that patient's wishes will be
respected.
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RATE FROM 1-5:
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| | | | VERY | |
| POOR | FAIR | GOOD | GOOD | EXCELLENT |
| 1 | 2 | 3 | 4 | 5 |
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1. How would you rate the candidate's communication skills?
1 2 3 4 5
2. How would you rate the candidate's ability to address the
ethical issue in this case?
1 2 3 4 5
You are now in the Emergency Department of the hospital. You are upset but not hysterical. You urgently want to know about your mother's status and what treatment is being undertaken. You have asked to see the physician looking after her. You begin by asking questions about her condition, e.g. How is she? How serious is it? Is she going to make it? What's been done so far? (Do not bring up the Jehovah's Witness issue right away.)
If candidate does not bring up the Jehovah's Witness issue, you could say things like:
Do you know she's a Jehovah's Witness?
Have you seen her card stating "no blood transfusions to be given"?
I hope you're not planning on giving her any blood.
A fundamental tenet of our faith forbids blood transfusions, and I know my mother would not want a blood transfusion.
If you want me to sign something I will. I don't want anyone here to be liable for what might happen. I know what my mother would want. I'll take responsibility for the decision.
As a Jehovah's witness, you believe that blood is the soul and receiving blood would defile the body, would make you "dirty" - like being "raped". You know your mother would not accept a blood transfusion because she would want to maintain her good relationship with God and obey his commandments. She would be willing to risk her present life rather than go against her religious beliefs. You know your mother believes she will be rewarded for complying with God's law commanding abstention from blood. You are sure this is for her everlasting good. Any medical procedures not involving blood would be perfectly acceptable.
You can carry a bible and be familiar with passages that support the tenet of "No Blood".
Acts 15:29
"That ye abstain from meats offered to idols and from blood...
from which if ye keep yourselves, ye shall do well...
Genesis 9:4
"But flesh with the life thereof, which is the blood thereof,
shall ye not eat..."
Leviticus 17:12
"Therefore I said unto the children of Israel, No soul of you
shall eat blood, neither shall any stranger that sojourneth
among you eat blood."
Leviticus 17:14
"For it is the life of all flesh; the blood of it is for the
life thereof: therefore I said unto the children of Israel,
Ye shall eat the blood of no manner of flesh:
for the life of all flesh is the blood thereof:
whosoever eateth it shall be cut off."
Be prepared to answer questions such as:
Is there anyone else who should be here to help make this decision?
What do you know about your mother's prior wishes?
Does she still believe in J.W teachings?
Is the card a valid reflection of her true wishes?
How do we proceed from here?
Do you know what will happen if we don't give her any blood?
Do you think your mother would still choose "no blood" if she
knew she could die?
Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.
PROMPT 1 (immediately):
How is my mother? How serious is it? Is she going to make
it? What have you done so far?
PROMPT 2 (by 2-3 minutes):
What happens next?
PROMPT 3 (by 3-4 minutes):
I don't think she would want a blood transfusion. (by 3-4
minutes) Do you understand what I'm saying?
PROMPT 4 (by 4-5 minutes):
Does she have the right to refuse the blood?
PROMPT 5 (by 6-7 minutes):
Are you going to give her any blood (transfuse her)? (by 6-7
minutes) What are you going to do?
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| |
| ***MEDICAL DOCUMENT*** |
| ***NO BLOOD*** |
| |
| Allergies:_____________________. |
| Current Medications:_______________________________ |
| ___________________________________________________. |
| Medical Problems:__________________________________ |
| ___________________________________________________. |
| IN CASE OF EMERGENCY, PLEASE CONTACT: |
| Name:______________________________________________. |
| Address:___________________________________________. |
|=========================================================|
| MEDICAL DIRECTIVE/RELEASE |
| |
| I, _________________, direct that no transfusions be |
| given to me, even though physicians deem such vital |
| to my health or my life. I accept nonblood expanders |
| (such as Dextran, saline or Ringer's solution, |
| hetastarch). I am ___ years old and execute this |
| document of my own inititiative. It accords with my |
| rights as a patient and beliefs as one of Jehovah's |
| Witnesses. The Bible commands: "Keep abstaining... |
| from blood." (Acts 15:28,29) This is, and has been, |
| my religious stand for ___ years. I direct that I be |
| given no blood transfusions. I accept that any added |
| risk this may bring. I release doctors, |
| anesthesiologists, hospitals and theri personnel from |
| responsibility for any untoward resuls caused by my |
| refusal. despite theri competent care. In the event |
| that I lose consciousness, I authorize either witness |
| below to see that my decision is upheld. |
| |
| Signature: |
| X________(signed) M. Montecino___________________. |
| |
| Witnesses: |
| 1.) X__________________________. Date:___________. |
| Relationship:____________________________________. |
| |
| 2.) X__________________________. Date:___________. |
| Relationship:____________________________________. |
| |
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