A 15 year old girl presents to the emergency department
via EMS status post a motor vehicle accident.
The patient is in critical condition
and is hemodynamically unstable.
It becomes apparent that the patient may require a blood
transfusion and the parents are approached for consent.
They are Jehovah’s Witnesses and
deny the blood transfusion.
However, the patient insists that she wants
the transfusion if it will save her life.
The parents again refuse.
What is the correct course of action?
Answer choice (A) - give the
patient the blood transfusion.
Answer choice (B) - do not give blood
transfusion due to parent’s refusal
Answer choice (C) - give intravenous fluids
to attempt to stabilize the patient
Answer choice (D) - consult
the hospital ethics committee.
or answer choice (E) - obtain a
court order to give blood products
Now take a moment to think of the answer
before we go through it together.
Now let’s attack this question.
This is a ethics question and this
is actually a 2-step question.
First we need to figure out wether or not blood
transfusion is life-saving for the patient,
and then we need to decide, “is it appropriate to
give to a minor whose parents are Jehovah’s Witness
and who are denying
Now hence, to the 2-step question.
And of course in this case, the stem is required
because there’s lots of critical information in it.
Now let’s walk through
this question together.
The first thing we need to do is determine wether a
blood transfusion is life-saving for this patient.
Now, this patient has lost significant blood
following the motor vehicle accident.
Now you could use intravenous fluids that can initially
provide relief to a haemodynamically unstable patient
but we still need to provide blood products
given the amount of significant blood loss.
Fluids themselves won’t give enough
hemoglobin back to do oxygen transport.
You can’t just give NS or LR, you do need true
hemoglobin and blood products to go back in
to do proper hemodynamics and to
give you proper oxygen carrying.
So in this case, a blood transfusion
is life-sustaining for this patient.
And that’s very important.
This is a emergency, life-sustaining and
life-saving decision we are going to be making.
That's how we are gonna get
around these ethical questions.
It’s not the grey area of, 'oh
is the patient fine or not?'
In this case, USMLE is only goinna ask you
clear cut questions regarding ethics,
and it is going to be essentially,
'is it a emergency or not?'
So that’s the first thing
we need to find out.
This is clearly an emegency - the patient's
been in a motor vehicle accident.
They'll tell you the patient's in critical
condition and they are haemodynamically unstable.
So we’re definitely in an emergency situation and
given the situation of significant blood loss,
we do need to give a blood transfusion to
provide not only hemodynamic stability
but also to give the blood back so that
we can do proper oxygen transport.
Now step 2 of this question is,
okay now we know well, we wanna give blood, it’s
life-sustaining, it's emergency - we wanna do that.
But we need to think, what are the rights of
this 15 year old girl to decide her treatment?
Now as a general rule, and you can use
this for all ethics questions for USMLE.
The interest of the child outweighs
the religious rights of the parent.
That’s a very important principle to understand.
You can memorize that,
I definitely would.
You’re going to see things like this in
all of USMLE step 1, step 2 and step 3
These kinds of quest do not go away.
So in this case, the interest of saving a child’s
life outweighs the religious rights of the parent.
That means in this case, the parents saying 'I don't
wanna give blood because we're Jehovah's Witness
and giving blood to us would be a way for
us to go like indefinitely into hell'.
That gets overriden when someone is going to die
in a clinical situation under your care.
So that's what that means.
The interest of keeping the child
alive in this critical condition
outweighs whatever religious beliefs
or rights the parents have.
Now as in this case, the blood
transfusion is a life saving treatment.
It does not require consent of the parent.
The patient is critically ill, they are
haemodynamically unstable, we do not need consent.
This is emergency, life sustaining
treatment, we can just save a life.
Now in the case of life threatening condition, minors
have the right to overrule the decision of their parents
with respect to their medical treatment.
So in this case, we have a minor whose parents are Jehovah's
Witness but she is critically ill and hemodynamically unstable.
So the correct answer is answer choice (A)
- give the patient the blood transfusion.
It is life sustaining and the
interest of saving the child’s life
outweighs the religious rights of the parents in a
critically-ill, life-saving emergency situation.
And that’s the case that the USMLE is going
to be giving you just like this question.
So now lets go through some
high-yield facts together
Let's talk about blood transfusion.
Now in the case of significant blood loss, a replacement
through blood transfusion is traditionally indicated.
Not very complex there - if you've lost lots of blood,
simply giving you fluids is not going to work
because we need hemoglobin, we need platelets,
we need plasma, we need coagulation factors, etc
Simple NS or LR doesn't have that.
Now if a patient is hemodynamically unstable,
giving fluids and also giving blood transfusion
is considered a life sustaining or
excuse me, a life- saving therapy.
Now, initially patients can be given IV fluids to kind of
short term control them while the blood products are obtained
from the laboratory, they’re
gonne be doing crossmatching,
they're gonna be making sure the
donor blood type is the same.
So correct, in the initial phase, and this could
be a separate question you may see in the exam,
we can give fluids to kind of maintain blood
pressure but we ultimately need to transfuse
and fluids are just a thing to buy
us time until the blood arrives.
Now let's discuss some
high-yield component of consent.
Now Jehovah's Witnesses do not accept blood
transfusion based on their religious beliefs.
This is not a belief based on medical
grounds, just their religious beliefs.
Although parental consent is generally
required for medical treatment,
that’s in the case of a NON life-threatening condition:
outpatient surgery, traditional clinic visits, yes.
You have to get the parents consent for a
minor but in a life-threatening condition,
the health of the minor overtakes
priority for any beliefs of the parents.
Now minors have capacity to make medical decisions
for themselves in life threatening conditions.
So again in this case, the young girl wanted to
receive the blood transfusion to save her life
so we will accept that because it is a life-saving
decision to provide in a critically-ill patient.
Now, let's just quickly discuss answer choices (D) and
(E) because these are gonna be common distractors
that you will see in other USMLE questions.
However in certain circumstances,
they may be correct.
Now answer choice (D) and (E);
(D) says, 'let’s go talk to the hospital ethics committee'
and answer choice (E) says, 'lets get a court order'
Now both these things are
going to take a lot of time.
You're gonna have to ask for a committee to come gather,
people there'll review the case, this could take days.
And getting a court order
will also take days.
You have a critically-ill, haemodynamically unstable patient
on your bed and and usually in an emergency room setting,
we don't even have an hour
to spare let alone days.
So both of those things are chronic things that you can do in an
outpatient slow setting, but not in a critically-ill setting.
So immediately we can
get rid of those two.
Answer choice (C) is correct, you can give fluids
but ultimately that's just a temporizing measure.
Answer choice (A) is what we care about the
most- give blood in a critically ill patient
and of course, answer choice (B) is wrong.
because we don't care what the parent say in
this case because the patient is critically-ill
and wants life-sustaining