ETHICS CASE QUIZ
Mr M is a 56-year-old unmarried man on disability who has a history of a right-sided middle cerebral artery hemorrhagic stroke, hypertension, alcohol use disorder, and prior upper gastrointestinal bleeding secondary to the alcohol use. He presents to the emergency department of a busy academic medical center with severe anemia. His hemoglobin level is 5 g/dL, and his hematocrit is 17%. Mr M is dysarthric from the stroke and so a difficult historian but does report episodes of epistaxis and melena. Review of the medical record does not identify any previous episodes of anemia serious enough to require transfusion.
He is immediately admitted to the ICU, where he provides signature informed consent for a transfusion of 2 units of packed red blood cells. The critical care team begins an extensive workup for the cause of the anemia. Over the next 2 days, the team is unable to establish a definitive diagnosis, and the patient requires another transfusion. His hemoglobin and hematocrit stabilize at 7 g/dL and 20%, respectively. His bleeding continues but has slowed, and he is transferred to the acute medical ward.
A lung lesion is found on a CT scan as well as diffuse lymphadenopathy. The hematology-oncology consultant suspects lymphoma and attempts a bone marrow aspiration and biopsy to make a definitive diagnosis. The procedure is so painful that after several attempts, the patient declines to try again.
Several hours later the daily labs return, and the patient’s red blood cell count is now so low that a transfusion is clinically indicated. The patient refuses and tells the resident physician that he is a Jehovah’s Witness and has religious objections to blood transfusions. He adds, “I was misled about the other transfusions . . . They told me they had transfused my own blood and I believed them, or I would not have let them transfuse me.” The senior resident carefully explains the risk of refusing the transfusion—including death—but the patient makes clear that “I would rather die than be transfused again.”
Dr A, the attending, is called and speaks to the patient at length. During the conversation, she explains that there are concerns he may have cancer. Mr M interrupts her and says, “If I have cancer or have to go through the pain of that bone marrow again, then I would rather just go home and take care of it myself.” When Dr A asks if he is suicidal, he says, “No, not now, but I have a collection of guns at home.”
Dr A is concerned the patient may not have decision-making capacity, especially as he becomes more anemic and frustrated. The attending calls for an urgent psychiatry and ethics consultation. While she waits for the consultants to arrive, she looks in the electronic medical record and the paper chart but cannot find an advance directive. No next of kin is listed, but the emergency contact is a girlfriend, S. Dr A calls S and explains the situation and her concerns. The girlfriend tells the attending, “I don’t care what he says! Transfuse him! He is talking religion, and I think he is crazy.”
The attending is conflicted. She believes that if the patient can be transfused and the workup completed, Mr M can at least have the facts he needs to make an informed decision. But without the transfusion he will die without knowing whether he could be successfully treated. Dr A knows and wants to respect Mr M’s wishes and beliefs, but she is concerned that his inconsistent decisions regarding blood transfusions mean he is not thinking clearly enough to make such a momentous decision.
You are the ethics consultant and arrive within an hour. The psychiatric consultant is finishing with the patient and believes the patient may be experiencing episodes of delirium, especially when he is profoundly anemic, alternating with periods of lucidity and so says he cannot really evaluate the patient’s capacity. The psychiatrist does not think the patient is acutely suicidal but was expressing his fear about the team’s inability to find out what is wrong with him and his anger about the pain and failure of the bone marrow puncture.
Dr Geppert is Professor, Department of Psychiatry, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque and Chief of Consultation Psychiatry and Ethics at New Mexico Veterans Affairs Health Care System in Albuquerque.