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Ethics case quiz: A patient's inconsistent decisions regarding treatment are cause for concern. What to do?
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.
Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. Please vote for your choices and post your comments below. A discussion of your comments and commentary about the ethical concerns and questions this case raises will be in a coming issue of Psychiatric Times.
As the ethics consultant, which of the following do you think is the central ethics issue in this case?
A. If the patient has decision-making capacity, he has the right to refuse a blood transfusion.
B. It is unclear whether the patient has a surrogate who is able and willing to make decisions that respect his wishes and values.
C. Since the attending has the ability to save the patient, she also has the duty to do so since she does not believe he has capacity.
D. The team believes the patient is incapable because he is refusing the clinically indicated medical treatment.
If the psychiatrist determines that the patient lacks decision-making capacity and the team cannot identify another surrogate decision maker, can S act on Mr M’s behalf?
A. Yes, because she is acting out of his best interests to save his life.
B. No, because she is not making the decision according to the patient’s preferences and values as she is required to do as a surrogate.
C. No, because only an individual who shares Mr M’s Jehovah’s Witness beliefs can be asked to make a decision based on religious grounds.
D. Yes, because there is no advance directive and so the surrogate has to make the decision she believes Mr M would make if he could think clearly.
One of the most important things to do as either an ethics or psychiatric consultant when a patient refuses a treatment-especially one that is lifesaving-is to try and understand why he is refusing. Which of these rationales do you find most plausible?
A. Mr M is expressing his autonomy in the only way open to him in circumstances where he feels he is not respected and has little control.
B. Mr M really believed that he was receiving an autologous transfusion and that his religious beliefs permitted him to accept his own blood.
C. Mr M is not truly a practicing Jehovah’s Witness but is refusing the transfusion as a way of indirectly killing himself without the psychiatrist being able to legally intervene.
D. Mr M did not really have decision-making capacity when he initially accepted the transfusions.
The attending is asking for your recommendations regarding whether to transfuse the patient. Which of these responses would you give to Dr A?
A. Transfuse Mr M so that his delirium can resolve and he can make an informed and reasoned decision regarding the transfusion.
B. Recognize S as the authorized decision maker and follow her wishes and transfuse Mr M.
C. Respect Mr M’s beliefs as a capable adult who can legally refuse a blood transfusion on legal grounds.
D. Obtain the agreement of a second attending physician and transfuse the patient using emergency consent.
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.