NoBlood

Eight years ago my sister was in a car accident. Broken jaw bone and broken leg. A south shore of Montreal, Quebec hospital admitted her.
Doctors and nurses took turns with serious accusations concerning my refusal for blood transfusion. Comments were outrageous like 'I suppose you don't care if your sister dies'. Although she did not loose her conscience during the ordeal staff maintained her cognitive state did not permit her to make decisions. Luckily the support of the rest of the familly for the no blood procedure helped although our 78 year old mother was pressured to make me change my mind.
During a visit I overheard a conversation between two surgeons who stated that they proceed with transfusions and simply do not tell the patient when they have to deal with ''this kind of people''.
Is it possible to withhold such crucial information? Has anyone heard of doctors simply proceeding to a transfusion without patient's concent or against his will without a court order?
To resume my sister is healthy and fine....never had a transfusion since familly took turns at the hospital day and night. Although the hospital refused for us to be in the room after visiting hours the waiting room was across the hall from her bed so we kept an eye on her just the same.

Dear Goudrea: I don't know if it would be legal to transfuse an objecting adult patient without consent (it is legally known as assault & battery), but if these surgeons admitted to doing so, I wouldn't overlook the possibility that they might proceed in the same manner again. It would be wrong to characterize all medical personnel as being so insensitive and downright violative of widely recognized patient rights, however, it probably does occur, as it apparently did in the case of your sister. I have overheard conversations between anesthesiologists and physicians expressing puzzlement as to why Witnesses refuse certain treatments and accept others, and frustration on the doctors' part when they have watched Witness patients die for what they feel is lack of a lifesaving transfusion. These sentiments are understandable, but should not be allowed to develop into or be expressed as abusive attitudes and treatment of Witness patients. It is really unfortunate that people must feel the need to watch diligently from some inconvenient vantage point so that their loved ones, or even themselves, are not subjected to some treatment they have indicated objection to. I have been told of one patient who stated she literally stayed up all night and wouldn't take pain medication or sedatives post-op because some staff member told her that they would come and give her a transfusion the minute she fell asleep! A patient treated in such a manner would have legal grounds to sue the doctors responsible and the institution for assault, battery, intentional infliction of emotional distress, and pain & suffering, among other causes of action. An assault, by the way, does not have to involve actual unwanted touching, but only the threat of or reasonable fear that such touching is imminent or likely to occur. The actual act of unwanted touching constitutes battery. I believe it would be difficult for a physician to justify doing any treatment to any patient without that patient's informed consent, or the consent of a duly appointed attorney-in-fact, such as you apparently were on behalf of your sister. Did your sister have a completed Durable Power of Attorney available for the doctors to read? This is SO important to have prepared long before any emergency comes up, and to be KEPT WITH YOU always. Please check out our upcoming December NoBlood Bulletin for more important nformation on DPAs!

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Jan Grossberg, RN, BSN
Editorial Team

Good day,
My sister had a hand written document indicating she appointed me however the doctors never bothered to ask for it. my familly was also aware who my sister wanted as PoA and supported me in front of the medical staff.
She realized that the situation could have gotten out of hand should doctors have requested a legal document. The whole familly now have a legal document naming a P o A
I was quite upset that 'some' doctors or nurses knowingly go against the patient's will. Since this incident I questionned friends and relatives working in the health care system .... non respect of the 'refusal of blood transfusion' seams more frequent than we may imagine.
Here in Quebec (a general practice ) is that social workers are systematically appointed to patients who 'seam" unattended by familly. These people are quite persuasive and overpowering and often times declare the person 'unfit' to take decisions. Even though my sister was very lucid.
A social worker kept visiting and insist that hb was too low and tried to convince my sister she would die if she did not accept blood (familly was present every day). Curiously the social worker tried to get her to sign a document to transfer her and her 'finances' to a long term facilty in SteHyacinthe stating she would be permanently handicaped (not walk again) if whe survived..
Sis walks has a full time job and operates a small farm on her own and didn't have or need a transfusion.
Thanks
M. L

I wanted to point out that, in certain regions of the world, even in so-called "progressive" or high-tech medical communities, there is still a great deal of paternalistic practice going on. The "doctor knows best" culture is very hard to escape from. This is something that is being addressed slowly but surely as the patients' rights concept takes hold. I'm sure you are quite aware that not all health care professionals come out of that mold, however. Many are really interested in respecting patient wishes. I think it depends a lot on the geographic area, and on the legal climate in the region, as well. Sometimes physicians feel they have to do a lot of stuff to cover themselves legally. As to the Hb being too low, there is at least one article I know of that debunks the traditionally accepted minimum hemoglobin level of 10 as somehow being the tipping point of Hb sufficiency in the body, even though doctors are still using it as the standard. Many people can survive really well with Hb levels much lower than that. Research has documented this.

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Jan Grossberg, RN, BSN
Editorial Team

Luckily familly members are involved in health care system some close friends are physicians or researchers, one of whom is actively working for the Régie de l'assurance maladie du Québec (approving medication) and a phd and professor at McGill University. This person readily teaches the new generation of physicians to mind patient's wishes.
I have spoken lately to a few nephrologists...they really don't appreciate to discuss erythropoietin with a 'novice' like myself. How dare I ask educated questions.
Most doctors do not appreciate natural remedies either. I have lately experienced the frustration of a group of doctors. A relative afflicted with 'shingles'. Zona in french. If you have ever seen what it looks like you never forget. On the web a Russian lab had posted their advertisement for a 'miracle product' ...a natural product unavailable in Canada. I tried to get info from 'Santé Canada' and the FDA ...no luck... finally left a e-mail to the lab. impossible to obtain the product in a reasonable delay (zona has to be treated within 24 hours max) so the lab agreed to give me the ingredients as long as I would not disclose them or market it. I boiled the concoction. The next day upon diagnosis from his doctor I offered the 'cream' . it worked no pain and only a few sores. Now his health care team want to know what was in my cream and are quite upset that I respect my non disclosure promise. Not all natural products are safe but some medication is produced from plants. I can't help to think that a patient has to get involved in his healing process and doctors don't have 'all' the answers.
Like you say in French ' La medecine n'est pas une science infuse' .
Good day,
M. Leroy

Here is an article that is encouraging. It's 6 years old, and some in the medical profession are notoriously slow to change their attitudes, but it's good to see that the need for change is acknowledged.

The Journal of Medicine and Philosophy, Volume 25, Number 6 / December 2000 pp. 701 - 721

Doctor Does Not Know Best: Why in the New Century Physicians Must Stop Trying to Benefit Patients

Robert M. Veatch

Abstract:
While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others – either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being.

Such scare tactics as goudrea describes are quite common. My wife, when she was in the hospital in Chicago, was told constantly "you know why you feel this way - it's because you didn't take a blood transfusion." She knew that she felt that way because of her low hemoglobin count. However, within 2 weeks from her hospital visit, her blood count was almost normal. The treatment? 40,000-unit shots of procrit. (I think she had 4 altogether). Her total length of stay? 3 weeks, 1 week of which really wasn't necessary. And that was with 2 back-to-back liver surgeries.

On another note, the "doctor knows best" mentality is present at all levels. Family practitioners / General practitioners (at least here in the US anyway) don't do any form of holistic evaluation - they treat the symptoms (you have depression? take this pill), rather than the cause (oh, medicine x causes depression. why don't we find something different?). Personal research is generally discouraged.

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Douglas Phillips

Thanks for the article you posted, David. I think the paternalism of the past is being chipped away at, but I still see it every day with even the female physicians who care for laboring women ( I guess that was a mistaken assumption on my part, that women doctors would tend to be less paternalistic.) I have to be very careful as a nurse to recognize that the patient has the right to decide how she wants to be treated, and my ministrations, however well-intentioned, must take second place to her wishes. I try very hard to give the patient all of the available information at my disposal, offer her choices, make sure she is aware of the potential consequences, and then listen carefully when she tells me what she wants. I work to accomplish that within the scope of my responsibilities as a nurse (i.e., there's some stuff I just have to do or endanger the patient, lose my license, etc.). But I make sure the patient has the choice to the best of my ability. What her doctor does is not up to me. Unfortunately, I have seen the doctors just decide for the patient what is "best". How do they measure that without finding out what the patient really wants? These docs (the ones I work with ) are so busy I am not surprised at some of their attitudes. Unfortunately, paternalism saves time.

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Jan Grossberg, RN, BSN
Editorial Team

Please give some of the jobs for nurses' in the hospital that does not require blood transfusions.

That is a good question. Almost the only unit I can think of that doesn't use blood often is the transition nursery. This is where babies who are well and stable are cared for, usually in the Postpartum (or Mother/Baby) Unit. Unfortunately, nearly every other unit in the hospital may eventually require a nurse to be involved with a blood transfusion.

Some hospitals respect the nurse's'religious objection to certain procedures (such as abortion, transfusion, etc.) but where I work, nurses are required to be willing to administer blood if necessary, even if they have a religious objection to taking blood themselves. There are ways to get around it sometimes, such as explaining your stand to a sympathetic fellow employee or charge nurse, so that another nurse could possible hand and connect the blood and you could simply monitor the patient for reactions. Or you might exchange duties with a co-worker (would you mind hanging the blood for my patient, and I will do [name the task] for you). Perhaps in Radiology the use of blood might not be an issue, but I am not very familiar with what the nurses there really do. Possibly the Rehabilitation RNs would have very little contact with transfusions.

I think contacting certain hospitals for ideas would be informative. Or, you could choose to seek employment outside the hospital setting, perhaps in a doctor's office, or look at Community Health settings. Unfortunately, they often require several years' clinical (read "hospital") experience before you can work there.

If you find any useful information on this topic, please post it in this thread for the benefit of others like yourself who may have similar questions. Thanks!

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Jan Grossberg, RN, BSN
Editorial Team