Tuesday, January 15, 2008

My Jehovah's Witness Story

It seems everybody has their JW war story. Here is mine.

A couple of years ago when I still worked at the CofE I was on call for neurosurgery and was called in one Saturday morning to give an anaesthetic for an aneurysm clipping. The patient was already intubated and had lines in (I call this plug and play). We put in the head pins started the surgery and I got down to reading the Saturday paper occasionally glancing at the monitor.

A former resident called neurosurgical anaesthesia " a gall bladder with mannitol". Despite all claims to the contrary neuroanaesthesia is dead easy. Various anaesthetic drugs have some effect on ICP and CBF and I did learn all these things during my residency. If you think too much you will be anaesthetizing all your patients with lidocaine and pancuronium because those are about the only drugs that don't do something bad. However after a while you realize that the neurosurgeons could not give a shit about what drugs you use, as long as the patient doesn't move, the brain is relatively slack and the patient wakes up when the surgeons wants them to (either right away or several days later). Further the patients either do well or badly and it has nothing to do with what you did (which doesn't stop the surgoens and worse still your colleagues from pointing the finger at you)

I was well into the sports section when somebody phoned into the room to tell us that they thought that the patient might be a Jehovah's Witness. Now aneurysms rarely require blood products (except for giant aneurysm and when those rupture you may as well just turn off the ventillator and go for coffee). So I did what the surgeon should have done before the case, I read the chart. I didn't find the blood refusal form but I did find a personal directive naming her sister as her power of attorney. Around that time somebody talked to her husband who stated that he wasn't aware that his wife was JW but that they had only been married for 6 months. Soon after I was told that the sister was on the line. By this time the aneurysm had been clipped. I told the sister that it was a moot point at this time but that given that her sister obviously wasn't a practising JW anymore would she consider allowing her brother-in-law to permit his wife to accept blood products. She of course refused at which point a man (presumably the father) came on the line and asked why we wouldn't use alternatives. I explained that we actually always used alternatives unless we felt that the patients life was in danger and hung up. The cranie was closed; another JW bullet dodged.

Not quite.

Around 1800, I got a phone call stating that I needed to come in for another cranie in this patient due to bleeding. Before I drove in I suggested they might want to contact the hospital lawyer about the possibility of giving blood products but nobody took my advice. The surgeon did talk to the sister who was still insistent on no blood products.

I was never clear on why the re-bleed occured. At the time it seemed that the patient had somehow become hypothermic and had developed a hypothermic coagulopathy. Her temperature was 33 and using all the resources at my command, I just couldn't seem to raise it. A quick internet search suggested that platelets might work in this situation but of course we couldn't give them. I of course can't rule out poor surgical technique and hemostasis. Anyway the surgeon poked around, cauterized and clipped for about 2 hours before closing up and we went off to CT to see whether we had accomplished anything. The CT showed a hematoma as big as the one we started with and we shipped her off to Neuro ICU presumably to die.

Now I of course felt sorry for the patient who may have died and at best would have been left brain dead. I also feel sorry for the husband whose wife of six months was now not the woman he married and hopefully was still in love with. All this because of the whim of his sister-in-law who, if he didn't know that his wife was JW, he probably had never met. Now many faiths have beliefs that are completely irrational, I am not going to give examples, you know who you are. It just seems that JWs consume a proportion of health care resources way in disproportion to their numbers. Consider everytime you have a JW coming in for major blood losing surgury, say a hip revision or liver tumour. These cases usually become a major military operation. There are usually consultations between multiple surgeons, hematology, ethics etc. Sometimes they even consult anaesthesia. The patient if he survives will have an ICU and hospital stay at least twice as long as normal.

Now you might ask, shouldn't we in a perfect health care system be prepared to do everything the patient wants to get him thru surgery. Yes, except that healthcare is a zero sum game. Service given one patient is service denied to another patient. If you spend an extra day in ICU, that is another patient whose surgery is cancelled, or who has to be looked after on the medical ward instead of the ICU or who has to transferred to another city or is on a ventillator in the recovery room.

Now somewhere in Richard Dawkins' book "The God Delusion" he pointed out that we are much more tolerant of irrational or stupid beliefs when a religion is attached to them.

Suppose I am about to undergo surgery where major blood loss is expected. Now I hate the Montreal Canadiens with a passion. I have decided that I will not accept blood from a Habs fan. Because the Canadian Blood Agency does not ask whether you like the Habs (which is in my mind WAY WORSE than paying for sex) I will not accept blood from them. Directed donation even if it were allowed would be out because I cannot be sure that my blood might be contaminated with a Habs fan's blood.

Even the biggest Bruins fan of a surgeon would flatly refuse to operate on me. There would be no meticulous planning, no ICU stay, no ethics consult. There might be a psychiatric consult.

An extreme example?. Only a question of degree. Afterall ethicists often justify the JW refusal blood by citing less extreme examples of other faiths (Catholics refusal of abortion, Jewish refusal of autopsy). It works both ways.

1 comment:

Anonymous said...

As a 23 year old male Jehovah's Witness i read this post and almost laugh at the stuff people write. of course its based on personal opinion not facts. Just off the top of my mind for one the comment that bloodless surgeries take longer recover time is a false because theirs a hospital in texas i think it was or arizona i don't remember that i just saw on the news recently that opened that prefers bloodless surgery and stated recovery time is half that of your typical blood transfusion surgery with of course no worries for diseases and body rejections.