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Patients who refuse treatment because of their religions beliefs sometimes contradict the most basic instincts of emergency personnel who are trained to save lives. Still, both legal and ethical mandates require ED physicians to respect a patient’s wishes. "If somebody comes in with a deep and abiding religious belief, we need to honor and respect that, even if it feels uncomfortable and wouldn’t be our wish for ourselves or them," says James G. Adams, MD, FACEP, clinical director of the department of emergency medicine at Brigham and Women’s Hospital in Boston.
The emergency physician’s role is to do whatever is best for the patient, he stresses. "You wonder if withholding treatment is contrary to the principle that we need to save a person’s life, but it’s not," Adams insists. "Our job is to promote the person’s health and well-being, but it’s for the person’s benefit, not ours. It’s as simple as that."
One example is Jehovah’s Witnesses, who refuse all blood and blood products, including potentially life-saving transfusions. "They have a profound belief that is different than the belief that we hold, and that creates a conflict," says Adams. "If the Jehovah’s Witness is able to affirm that belief in the ED and refuses blood, we’re not to force blood on them."
The scenario can be uncomfortable for emergency physicians if a life could be saved with blood, he says. "But the Jehovah’s Witness believes that blood severs their relationship with God and prevents them from obtaining everlasting life, and who are we to interfere with that very powerful belief? We’re not supposed to," Adams emphasizes.
A patient’s refusing treatment for religious reasons is often difficult for emergency physicians to accept. "In the case of a hopeless medical condition like Lou Gehrig’s disease, where body is just not functioning and they don’t want treatment, to some degree we can understand and sympathize with that patient," says Adams.
It’s harder to sympathize with a otherwise healthy patient who refuses treatment for religious reasons, he notes. "But that is evidence that our own values are intruding, and we have to be cognizant that we’re practicing medicine according to the values of the patient and not our own," says Adams. "We have to be particularly astute in making sure we do what the patient perceives as [his or her] best interest and not to impose our own values."
"We’re not able to easily assess that in the ED, because we don’t know the people and may have limited access to their family members, or not be sure what to make of opinions of relatives," says Adams. "So we end up resuscitating and caring and doing things to people that we think are going to help them, and for most patients that’s the right answer."
In Orthodox Muslim religions, female patients may not want to be examined by a male physician, or give their own medical history. "In some religions, the husband does the speaking, so the history comes from him," explains Adams. "We want to talk to the woman, we want privacy for the woman, we respect autonomy of the woman, but the religion doesn’t, so it’s very uncomfortable."
For example, a Muslim woman may complain of abdominal pain, but insist on remaining completely covered during an examination. "The man is always with her, and it’s often very difficult because the husband will relate the story and want the doctor to initiate treatment at that point without examining the woman," says Adams. "Both the husband and the woman would feel a great violation for a man to do any kind of intimate examination."
Sometimes a compromise can be reached after trust has been established. "Sometimes I can palpate through the veils while I am talking to the husband, with their consent, while he is watching my hands very carefully, without without the sense that we’re violating the woman or the religion," says Adams.
It’s important to respect the patient’s privacy. "If a fundamentalist Christian contracted a disease doing something they shouldn’t have been doing, then the issue of confidentiality comes to the forefront," says Adams. "There are times when we’re taking care of very personal issues, and the patient may not want their family to know."
ED physicians should be prepared to make judgment calls. "Policies are written for the clear circumstance, when there is abundant evidence, but that’s not always the case," says Adams, who recalls an unconscious 17-year-old victim of a motor vehicle accident being resuscitated in the ED on full life support. "His blood pressure was low, liver was lacerated, spleen was bleeding, and he needed to go to the OR immediately, but he wouldn’t survive without blood and lots of it," Adams recalls.
The boy had a signed card in wallet saying he was a Jehovah’s Witness, and his mother and minister were present insisting blood should not be given. "The hospital took guardianship away from the parents and starting to give blood emergently in the OR when it became absolutely mandatory, otherwise we would have started in the ED," says Adams. "He got lots and lots of blood and recovered."
When the boy’s mother saw her son in the trauma ICU with blood bags hanging, she began screaming, "You’re raping my son, please stop the blood!" and had to be physically restrained by security. "It doesn’t feel good, we were in a no-win situation," says Adams. "But he recoveredhe wasn’t happy about getting blood, but he was happy to be alive."
Because the patient was under 18, the hospital was able to apply to the courts for guardianship. "He was on the cusp of independent adult or dependent minor, and he wasn’t really either," says Adams. "In cases like that, even when the rules do apply so we could invoke that he was a minor, you just don’t feel good about it. But if we let him die, we might feel worse."
Afterward, hospital staff met with the church elders to discuss the incident. "Did we impose our values? We certainly did," says Adams. "Did we do the right thing? Who knows, it’s open to interpretation."
ED staff should be familiar with the religious beliefs of the community they serve. "We need to get to know the religions of the people we serve," says Adams. "The rule for the emergency physician when a patient is behaving differently than we might expect, is seek understanding first. If we do that, we’re less likely to misstep."
Members of religious communities are generally willing to meet with ED staff to explain their beliefs. "We meet with doctors, not necessarily to preach, but to clear up any misconceptions about our beliefs," says Vince Vellucci, chairman of the Atlanta Hospital Committee for Jehovah’s Witnesses. "We build up good relationships in advance, so we can avoid difficulties when an emergency occurs at 2:00 a.m."
A personal meeting may bring the point home. "A forced blood transfusion would have a long lasting, traumatic effect," explains Carl Bruce, head of hospital information services for Jehovah’s Witnesses in Brooklyn Heights, NY. "The analogy we’ve used is a rape, because we’ve been violated."
Here are tips to consider when managing patients who refuse treatment on religious grounds:
Be aware of state statutes. "It’s real important, risk managers need to be aware of case law in particular state because this is not a federally dictated area," says Sue Dill Calloway, RN, MSN, JD, director of risk management for Ohio Hospital Association in Columbus, OH.
Stay abreast of legal trends. "The current trend in law is to respect the right of patients to decide what is right for their own body. A lot of courts won’t intervene, especially against religious beliefs," says Dill. "We’ve seen a significant change not only in judicial thinking, but also in legislation asserting that patients have this right."
"The law recognizes an individual’s autonomy to make their own health care decisions as long as he or she is competent, and won’t harm other people, such a delusional patient shooting someone, or a patient with a communicable disease.," says Louise Andrews, MD, JD, FACEP, an attending physician at the ED at North Arundel Hospital in Baltimore and a consultant in medical-legal matters. "You can use powers of persuasion and reason with these people, but in the end you have to let them make their own decisions, as long as sure they know what the consequences are."
Don’t hesitate to get a court order to save a child’s life. "Most states will not allow parents to make decisions that would result in the death of a 4-year-old, and we would go in and get a court order for treatment." says Dill. "Some parents have been prosecuted for child endangering because prayed for their child instead of seeking treatment."
If the parent refuses treatment that would save a child’s life, ED physicians need to get permission from another source, says Andrews. "Even if it is a firmly held belief the child wants to go along with, you have an obligation to look for a guardian from a legal source to allow the child to survive until they are old enough to make that decision for themselves." says Andrews.
Parents who depended on faith healers have been prosecuted for not seeking treatment for their children. "There have been a number of court cases with children with meningitis, which is uniformly fatal if not treated with antibiotics," says Andrew. In one instance, when the child did not receive treatment and died, the parents were convicted of manslaughter.
Decide if patients are competent. Laws vary according to states, but general rule is the emergency physician can make that determination without a psychiatric consult, says Dill. "If the patient is answering questions logically, and knows where he is, who the president is, the physician can make an assumption the patient is competent," says Dill.
Have a policy in place beforehand. "It’s important for every facility to have proactive risk management on this, so when it happens a nurse can go to a policy that’s been looked at by the hospital legal counsel, which is consistent with Joint Commission standards and state case law," says Dill. " You don’t want to wait until it happens to you at 2 a.m. to find out what your institution is going to do."
In an Ohio case, a female Jehovah’s witness slipped into a coma, and her husband, who was not a Jehovah’s Witness, signed a consent for emergency blood. The patient later sued the hospital for giving her blood. "But because a court order had been obtained, the hospital was found not liable," says Dill.
Don’t make assumptions about a patient’s religious belief. The individual patients themselves have to be the spokesperson, not family members. "A patient may be a member of a church, but may not agree with all the provisions of that religion," says Dill.
Document carefully. "Documentation is what’s going to save you," Dill emphasizes. "You want to write right on the AMA form what doctor has told the patient about the risks of refusing treatment. There should be clear documentation in the medical record as to what has transpired."
Offer alternative treatments. If a patient refuses treatment, try to offer alternatives. "You have an obligation to do whatever is available so they aren’t harmed further by their decision for ethical reasons, but it’s also a wise decision from a liability standpoint," advises Andrews.
According to Joint Commission Standards, ED physicians should be sensitive to patients’ religious beliefs and offer treatment which doesn’t conflict with their religion, says Dill. "If prayer is important to them, ask if treatment can be done in addition to prayer," she suggests.
Consider the patient’s previous psychiatric history. "If a patient has a history of saying they are the pope or Jesus Christ and don’t want to be treated because they think they can’t die, then you have to make the safest decision for that patient based on other things besides their professed religious belief, at least until they recover from delusional state," says Andrews. For all you know this person is not competent because they were unconscious, had low blood sugar, or suffered ahead injury.
When in doubt, err on the side of preserving the patient’s life. "As an emergency physician, I would be much more comfortable going to court and explaining to a judge that I did what I thought was best, and maybe I did the wrong thing but my mission is to save lives, than to say the guy refused treatment, and I said good riddance," says Andrews.
Don’t let fear of being taken to court affect a patient care decision. While emergency physicians should be aware of potential legal risks with patients who refuse treatment on religious grounds, decisions shouldn’t be made solely on that basis. "The legal system has a special interest preventing suicides, preserving life, protecting third parties, and in protecting integrity of the medical profession, if we are aware of them will most likely remain safe," says Andrews. "Most physicians are in good stead if they do in their good faith belief is in the best interest of preserving life, safety and health of any given patient."
Realize the patient may be delusional from injuries. "A patient may come in after an auto accident and say God doesn’t want them to get treatment, but five days later they may not remember what they said," says Tallien R. Perry, an attorney specializing in health care law in Los Angeles. "You need to get a psychiatric evaluation, and if there is any doubt about whether the person is capable of making a decision, you’re always better off to treat."