Ethics in nursing
By Kelsie Lang, Jess Wagner, Rachel Ausenhus, Amanda Rablin,
and Claire Nieman
THE FACTS
• Name: Juana
• Female
• Black Hispanic
• 20-year-old
• 32 weeks pregnant
THE STORY
Brought to the ED after a single- Lab Findings:
vehicle collision • Hgb: 6 g/dL
• Hct: 21%
Assessment Findings:
• A&O x3 Diagnosis: internal bleeding
• Glasgow Coma Scale: 15/15
• Lightheaded/weak Plan of Care: immediate blood
• Left shoulder pain transfusion and emergency
• Severe abdominal cramping cesarean section
• RR: 28, lungs clear bilaterally
• HR: 90 Complication: refusal of blood
• BP: 130/80, orthostatic products based on Jehovah’s
changes (BP: 100/60, HR: Witness faith, as supported by
120) advance directives with blood
• Fetal Pulse: 90 distress product prohibition
“I would rather be embraced in the hollow bosom of Jehovah than to be
condemned for all eternity.” --Juana
Ethical Principle:
Autonomy
• The patient needs blood products for her and her
child to survive, but the patient also has the right to
refuse blood products.
• Does the patient have a right to reject blood products
on the basis of religious integrity?
• How should the healthcare team approach the rights
of the patient’s child?
• If the patient refuses blood products, what is the most
the healthcare team can do?
Blood Transfusion
• Hemoglobin (Hgb): The substance inside red blood
cells that carries oxygen and gives red blood cells their
color.
• Normal = 12
• Hematocrit (Hct): The percentage of your blood that
is made up of cells rather than plasma.
• Normal = 37.7%
• Hemorrhagic Shock: A condition where there is
inadequate tissue perfusion, usually due to significant
blood loss.
Questions to consider
• What were her hematocrit levels? Was there hemorrhagic
shock?
• Hgb level was 6g/dL, and Hct was 21%
• What were her vital signs?
• She started showing signs of OH
• BP dropped from 130/80 to 100/60, and heart rate increased
from 90 to 120
• Were there signs of impaired oxygen?
• Was there continuous bleeding?
• She was bleeding internally, and needed a C-section
The patient’s beliefs
• Jehovah's Witnesses are permitted medical treatment
with the exception of blood transfusions.
• Abstaining from blood is considered an area that
identifies them as the ‘only true religion’.
• “Those who respect life as a gift from God do not try to
sustain life by taking in blood.”
• "Jehovah’s Witnesses do not accept transfusions of
whole blood or the four primary components of
blood namely, red blood cells, white blood cells,
platelets, and plasma. They also do not donate or
store their own blood for transfusion."
“Instead we should write to them,
telling them to abstain from food
polluted by idols, from sexual
immorality, from the meat of
strangled animals and from blood.”
Acts 15:20
Alternatives
• Some individual Jehovah’s Witnesses allow pre-
operative self-transfusions for storage
• Volume replacement and oxygen administration
• Autologous transfusions part of a “current therapy”
• Cell Saver: intraoperative RBC salvage
The Decision
• The caregivers respected Juana’s autonomy not to
receive blood transfusions or a caesarean section.
• The staff allowed the patient to stay true to her
religious beliefs but in the end it resulted in death.
• Had she followed the physicians recommendation she
may have survived but would have violated her
religious beliefs.
Our Thoughts
• As a group we also thought that the patient should have her
say in what happens as long as patient was in a stable
position to do so.
• However, we would include a lot of education and risk
factors. We would want the patient to look at every option
and understand every possible outcome, before being able to
just refuse a transfusion.
• We would ask the Chaplain and other support services to
come speak to the patient for comfort as well.
• In the end we do believe that the patients autonomy should
be respected and valued
What has developed
since the case?
• There is now a waiver that patients must sign, in case a
patient refuses a transfusion. The waiver basically
removes legal responsibility from the hospital and
caregivers.
REFERENCES
Braithwaite, P., Chichester, M., & Reid, A. (2010). When the pregnant Jehovah's
Witness patient refuses blood: Implications for nurses. Nursing for Women’s
Health, 14(6), 462-470. Retrieved from: http://onlinelibrary.wiley.com/doi/
10.1111/j.1751-486X.2010.01593.x/full
Cahana, A., Weibel, H., & Hurst, S. A. (2008). Ethical decision-making: Do
anesthesiologists, surgeons, nurse anesthetists, and surgical nurses reason
similarly? Pain Management, 9(6). 728-736. doi:10.1111/j. 1526-
4637.2007.00346.x
Pacsi, A.L. (2008). Case study: An ethical dilemma involving a dying patient. Journal
of the New York State Nurses Association, 39(1), 4-7. Retrieved from: http://
www.nysna.org/images/pdfs/communications/journal.spg_smr08.pdf
Schroeder, A., & Kache, S. To Transfuse or Not to Transfuse. Retrieved from: http://
peds.stanford.edu/Rotations/picu/pdfs/24_transfusions.pdf
Varelius, J. (2006). The value of autonomy in medical ethics. Medicine, Health Care,
and Philosophy, 9(3), 377-388. doi:10.1007/s11019-006-9000-z
