Monday, July 09, 2007

Blood Oath

Couple of good posts by ema, and Dino, about the obligation of doctors to provide standard care even if it conflicts with personal religious beliefs. For the record, I couldn't agree more: doctors who feel they can't do certain medically necessary procedures or prescribe certain drugs only for religious reasons ought not to be in the field with which they find themselves in conflict. From the other side of that coin, here's a related story:

When you get a call from a doc who, for various medico-political reasons never calls, you have to wonder what's up. Terrible case that he wouldn't want to dump on a buddy? No insurance? Three a.m.? Usually, yeah, one of those. This was a call to the ICU in the middle of the afternoon, which eliminated one explanation off the bat.

The smell of blood in stool is unmistakable. Metallo-putrid, it lets you know what you're in for several doors away from the room to which you're headed. You can even guess whether the bleeding is in the stomach, or the colon, because the former passes through the small intestine, where digestion affects the odor. Even more: the faster the bleeding, the less digestion. A good nose can tell you things before you enter. In this case, I was clued in from well down the hall.

Curled around and resting her chin on a stainless-steel pan splattered red, lying on absorbent blue pads stained with the maroon of partially digested blood at her backside was a woman in her forties, pale, looking frightened and miserable. Her husband was standing by the head of her bed, mutely and resolutely holding a cloth on her brow. The attending doctor, whom I knew vaguely but with whom I'd not worked professionally, looked up as I approached and head-waggled me to a halt in the hallway. "Thanks for coming," he said, hustling toward me and sticking out a sweaty hand. "Tough situation. Jehovah's Witness, bleeding like stink, refusing blood. She's got a duodenal ulcer, I saw it on a scope. Surgeons A, B, and C wouldn't come see her. I appreciate you being here." Maybe I was young and naive, or maybe I was right: I couldn't fathom those other docs refusing to engage. It dawned on me that if I were to operate and do something that caused more bleeding, and if she died for lack of the blood needed because of my error, things could take on an entirely different aura. Still, I didn't see how I could walk away and let her bleed to death. I went into the room.

Some ulcers bleed and stop on their own. If they start up again during the same hospitalization, the odds get serially less and less that it'll heal without surgery. This lady had bled and stopped, and was bleeding again, fast. At least one of the other surgeons had been called during the initial bleed, as he should have, and when she ought to have been operated. Given her refusal of blood, she was hovering very near to deadly danger, and the decision to operate was clear-cut in my mind, and urgent. I told them so. "Just to be clear," I said to the woman, including her husband in the sweep of my eyes, "You refuse blood under all circumstances, even if it means bleeding to death?" It's what we believe, they both indicated. "Blood products, plasma, everything?" "Yes." "OK," I said. "The odds are this will be pretty straight-forward. I ought to be able to get the bleeding to stop. But, you know, nothing is for sure. It could take much more than it seems right now. And surgery always causes some bleeding. No matter what, her recovery period is complicated by her very low blood count. As clearly as I can see it, the odds of getting through this are significantly better if we operate, but I have no crystal ball. She might stop without it, and heal. She could succumb either way. It's just that I think there's more control at this point if we operate. And if you really refuse to receive blood no matter what, I'm prepared to accept having her bleed to death in my hands." I wasn't sure I was, but that's what I said. Plus, I really didn't expect to have to face such a scenario. Surgery, after all, is good for you.

I motioned her husband to come with me into the hall. "I'm OK with this," I told him, "but I don't really like it much. And, just so you can think about it ahead of time, I want you to know that if we get into the soup in there, and if I think the only way to save her is to give her blood, I'm coming out into the waiting room and telling you and asking for a final time." He gave me a leaden and eye-contact-free nod, saying nothing. A nurse came up with a clipboard. "Shall I have them sign the blood-refusal form now, Doctor?" "I don't know, I don't care... uh, sure, have them sign it. Both of them. Not that it'll make any difference..."

When time is of the essence, you do everything you can to save minutes, from calling ahead to the OR and telling them it's urgent enough to "bump" a case out of the schedule, going there and helping set up the room, to wheeling the patient down there yourself. Let anesthesia know what's happening, help put in extra IVs, make it a quick prep, shortcut the scrub time. I've described techniques for rapid incision in previous posts; it takes only a minute or so to get in and get the stomach into your hands. These kinds of ulcers are usually within a centimeter or two of the pylorus, so you quickly elevate it by placing a couple of traction-sutures, and cut across it longitudinally. Sometimes the bleeding artery spurts in your face: a finger into the hole gains temporary control, while you place a strong suture on a big needle underneath, then lift it up. Now you have it. The typical arterial culprit runs vertically behind the pylorus, so two stitches, north and south, are what you need. Another stitch like the first, and the bleeding is over. When it is.

It's nearly magical: as soon as you get that bleeding stopped, faster than it takes to refill the tank with fluids, the rapid pulse of hemorrhage slows down, as if the body senses the sealing of the hole and relaxes, even before the lost volume is replaced. You can hear the decelerating beeps on the monitor, and it's like a musical exhalation. When it happens.

Before every operation, I get psyched up: for some, of course, more than others. Sometimes there's great anxiety, concern over what I might find, over whether the existing circumstances are such that I could encounter terrible problems. I bring to bear all the concentration I can muster, focus everything I have -- experience, knowledge, judgment, technique. Knowing that -- probably most patients really don't consider it -- you'd think anyone about to go under the knife would want to avoid like poison putting constraints on the surgeon, interfering with the process; eschew limiting the options, interfering with carrying out the procedure in the best way possible, making specific demands, tying -- of all things -- his/her hands. There have been times when I've responded to certain demands by saying I couldn't, on the basis of my best medical judgment, provide care for the patient given the demanded restrictions. Never, for reasons I can't explain, because of religious objection to blood. In fact, I was on the JW list of "bloodless surgeons."

When I ran my malpractice series (one, two, three) a while back, I got several comments from attorneys. I'd welcome them here. Correct me if I'm wrong: the law covering this stuff is all over the map. In general, doctors haven't been held liable for untoward outcomes deriving directly from blood refusal; but there have been unfavorable judgments when an operation caused bleeding that led to death or complications, even if those outcomes could have been easily avoided by transfusion. Anecdotally, I've heard of doctors being sued for not giving blood (when giving it was contrary to the patient's directive!) when the patient died. And, of course, for life-saving transfusion that led to recovery, but were against patients' wishes. It's grayer still with kids. Court orders have been sought, not sought, granted, refused.

There's a difference, in my mind, between my acceding to patients' religious convictions, and forcing mine on them. It's a question of who's got the power. I could have said no. In the reverse situation, a patient may not have alternatives. A doctor's highest obligation is to do what's medically right for the patient, regardless of that doctor's personal beliefs. Clearly, there's not always a perfectly clear border between medical judgment and personal beliefs. If my choice of a particular operation differs from that of another surgeon, how can I say certain "morality" issues haven't been at play? Quality of life. Predictable time remaining, chance of helping... Still -- recognizing that judgments are made of more than book-learnin' in medicine -- a doctor shouldn't be able to refuse either to provide or to arrange for the obtaining of recognized and standard treatments because of religious belief, any more than a firefighter ought to be allowed only to save those people in a burning building with whom his moral judgments are in conjunction.

I've operated on lots of Jehovah's Witnesses; I know surgeons who never would. Same with people with AIDS. I've been fine with patients using all manner of "alternative" and useless methods, as long as they were adjunctive to rather than supplanting what I thought was best. On at least one occasion, I've agreed to do a lumpectomy for a woman with breast cancer who told me in advance that she refused further conventional treatment and planned to take treatments that I knew to be bogus. Figuring she had at least some chance of cure with the tumor gone, I did what she wanted, while trying like hell to talk her out of her plan. I even encouraged her to keep seeing me so that when the nearly inevitable recurrence happened, we'd find it as soon as possible. (It did; we did; but it was still too late.) I've taken a perfectly normal appendix out of someone planning to climb Mt. Everest, and have removed an asymptomatic (but stone-containing) gallbladder from a person leaving for missionary work in a medically-deprived area.) I guess the common thread is the ability for give-and-take. When lines are drawn, on either side, based only on (most often) religious beliefs, allowing nothing across but a thrust-out chin, the whole relationship is chilled, and bad things can happen. Not that it'll ever change.

[Edit: a reader pointed out I never said what happened to the lady in question: piece 'o cake. She did fine.]


justme said...

Thank you so much for helping me to see the situation from the surgeon's point of view. You are helping relationships and probably making surgery safer for a lot of us.

FetchingGal said...

Did it end the way I think it did with that woman who had the bleeding?

Pursey Tuttweiler said...

The Jehovah's Witnesses have a reform group of Jehovah's all over the world, including doctors and members of the general public, who are trying to get the blood refusal practice changed. They have made some headway, and believe it is a tragic mistake not to accept blood, but I have a family member who is a witness and I know that she will not. I do not know how you mentally made it through that surgery, but I have a feeling that if you had to give her blood and told the husband that an emergency had occurred he would have relented. The reform group wants all forms of blood accepted as long as the patient repents later, but with Jehovah's, shunning is still in practice and if repenting involved fessing up in front of the elders shunning may still be called for. It is quite a problem for surgeons and for non-Jehovah family members who hate to see their loved ones die over this belief.

Sid Schwab said...

fetchinggal: no

Sid Schwab said...

fetchinggal: I meant yes

Eric, AKA The Pragmatic Caregiver said...

Oh great healer. . .

Have outcomes improved with the wider availability of EPO-type agents? It would seem to me that, in the event of elective surgery, you could buff them up with iron and EPO, and continue that therapy during the recuperative period.

I know that JWs insist that autologous blood transfusion is just as shun-inducing as homologous blood, and that they've had angels-dancing-on-heads-of-pins discussions about cellsavers, crystalloids-backed dilution and reinfusion, etc. I agree that as a surgeon, the issues around children would be exceptionally problematic from a moral perspective.

Un-PC Opinion Starts Here:

I have to say that I would move in a different direction on this; there's probably good reasons I don't practice medicine, but I think it's reasonable to refuse to provide care when the patient isn't willing/able to participate fully in their own recovery. If you're actively making your outcomes worse either through overt action or inaction, in light of scarce resources, I don't feel doctors have an obligation to do all the heavy lifting on their own.

Eric, Bad Person

FetchingGal said...

Ok that clarifies things... LOL

If by no, do you mean she had surgery, survived, went home and got on with her business then?

Sid Schwab said...

always-thoughtful Eric: I'm aware of using EPO to treat post-hemorrhage anemia:

and of using it pre-operatively for operations with high risk of blood loss, eg cardiac, hip replacement.

And it's true, except in certain emergency situations, that doctors indeed have the ability to opt out.

Jeffrey Parks MD FACS said...

Last month of my chief year we did a whipple on a JW guy. He did fine. It cracks me up to read pamphlets put out by hospitals praising their "bloodless surgery" innovations. What a catchy phrase. Ive had patients ask me, "do you do bloodless surgery" No, I try to exsanguinate my patients to the verge of death. Ridiculous. It's like saying We do Sterile Surgery! Good technique means finding the right planes which usually limits blood loss.

Bongi said...

i can't even imagine refusing to operate someone with aids, and yet you mention it, so i assume it's relevant there???? can that be??

in our setting, a large proportion of our patients only present after spending a small fortune on the local sangoma. once again i can't imagine not treating them because they chose to throw their money away for the added benefit of making the condition worse.

yet in your country where there is a labyrinth of legal pitfalls around giving vs not giving a jw blood when it may or may not save his life, i can understand deciding not to get involved. yet when you are the last option? i don't think i'd be able to refuse in the heat of battle.

in our country if they refuse blood and you don't give it i think you're legally pretty safe.

Anonymous said...

In the jurisdiction in which Dr. Schwab practices (Washington state), there is an appellate case on the issue of assuming liability for refusing blood. Interestingly enough, this case came out of the same county and hospital in which Dr. Schwab practiced, and older members of the medical community still remember it. Shorter v. Drury (103 Wn.2d 645, 1985) held that even if a JW signed a release assuming the risk of refusing blood transfusions, a physician could still be sued for negligence for causing the situation that required the use of blood to save the patient. A jury awarded $ 412,000 and the verdict was reduced by 75% for the patient assuming the risk of refusing a blood transfusion.

So the current state of the legal art in Washington is that a physician can still be sued if they agree to withhold blood and the patient dies, even after signing a release. Whether the physician wins or loses the suit is not as important to the average physician as is the fact they can be sued at all. Because of this, many physicians in this state are concerned over their legal liability in this area.

Many physicians in this area also have ethical qualms over allowing a patient to die from refusing blood and see this as conflicting with their own moral or religious values. This is especially true when dealing with children or pregnant women. There can be less of an ethical concern with a competent adult who signs a release, but you still have the malpractice suit potential.

And unlike what happens on TV, where attractive young lawyers are able to get an emergency court order in 15 minutes ordering a physician to provide treatment against the patient’s or parent’s wishes, real life in this area is somewhat different. Our courts operate 9-5, M-F, and there is no judge on-call in the evening or weekends for this sort of thing. When I suggested this to the Snohomish County presiding judge, he just looked at me and chuckled.

So these are situations with no easy answers for the physicians, and it raises the question as to whose moral and religious beliefs should take precedence: physician or patient.

The Enormous Clinic

Sid Schwab said...

TEC: thanks for that. I had that case in mind when I mentioned the legal spectrum. You are a solid back-up, like Lloyd's of London, only closer.

Unknown said...

Concerning JW's, will they accept transfusions of their own blood? Seems like a reasonable compromise might be to convince them to bank their own blood in case of emergency or for an upcoming surgery. All you'd be doing is taking it out, storing it, and putting it back in. I don't know enough about the religion to decide whether that would be acceptable.

Anonymous said...

As with most matters of religious beliefs, there is a wide spectrum of opinion on use of blood and blood products by JW. In my neck of the woods, I have encountered JW who will allow no blood, blood products, Cell-savers, autologous blood donation, some volume expanders and the like. I have met other JW patients who will allow any of them. The Cell-savers seem to be accepted by a pretty high percentage of the JW patients in this area.

The Enormous Clinic

Anonymous said...

The following website summarizes 300 U.S. court cases affecting children of Jehovah's Witness Parents, including around 100 cases where the JW Parents refused to consent to life-saving blood transfusions for their dying children:


Lynn Price said...

"Shorter v. Drury (103 Wn.2d 645, 1985) held that even if a JW signed a release assuming the risk of refusing blood transfusions, a physician could still be sued for negligence for causing the situation that required the use of blood to save the patient."

Bloody marvelous. So docs now have to be lawyers. I can see why doctors A, B, and C passed on Sid's JW patient. Horrible. Sid, you took a real chance with your career.

Mitch Keamy said...

Sid. Nice post on a seemingly tough topic. As a cardiac and neuro anesthesiologist, I too, deal with this issue from time-to-time. I liked the talmudic way you parsed the situation in your discussion with the couple, and the business of coming out one last time to ask the husband what he wanted to do if necessary, was solomonic; your thinking on this case will inform my future care. Thanks, colleague.

Greg P said...

To a large extent, this goes back to centuries old beliefs about there are "humors" in the blood that cause your temperament, and the fear that you can be poisoned by someone else's blood. Not helped by the discovery of HIV years ago.

And there is famous literature keeping these fears alive, like Frankenstein, Dracula, and the werewolf lore.

The odd thing about JWs is that this is not the same as those who refuse all medical care and rely on "God" to cure them.

Anonymous said...

Try as you may, you just can't help some people.

Excellent addition to Grand Rounds. I really enjoyed reading this.


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