Actually, I do not feel that way. How often did you revisit the issue of blood transfusions? I did bring it up on a number of occasions, especially when she came to the clinic. I just wanted to see if her mind had changed over the span of time, and it never did. She was unwavering in her belief, and I respected her for that. We worked on making sure that she understood what would happen to her without blood.
She understood all of it, and she was petrified. She was very scared. Please pray for me. I think this was a bigger issue for the nurses than the doctor. The nurses are more hands on and closer to the suffering. I was never conflicted about what we were doing, especially given the fact that she was a nurse.
Getting his life back
I felt that she really understood the implications of her decision. Even after she received her first cycles of chemotherapy, she decided that she wanted to go on, knowing how bad things could get on chemotherapy. She still made the decision to forge ahead, even knowing that the odds of survival were slim. Consistently, courts have upheld the rights of competent adults to refuse lifesaving treatment. Yeah, sure. It weighs on your mind. I thought about it a lot. I think that the only thing that you can do is try to present things as realistically as possible and hope that they understand. Guilt is an interesting response.
They had chosen their ground rules, and we stuck within their ground rules. I think, under those circumstances, we were giving her our best effort. That point came during her last admission when things became critical and I knew that hanging blood could potentially save her life. Then, I did feel very conflicted in my role. As a physician, I wanted to help her, and I wanted to do everything that I possibly could to help her. As a person, as her friend, I completely respected what she wanted to do. It was never really an issue for me until the end when I felt that she was suffering from the anemia.
That was hard for me to watch. I think the other part of this that strikes me is the ambivalence in the patient. Here was somebody who really wanted everything, and there seems to be a contrast.
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I think that your point touches on the issue of informed consent. If you sit there and discuss with someone from today until next week about a future bone marrow transplant, does the person truly know what that transplant is going to entail? After seeing a number of bone marrow transplants, I would think a lot more carefully about undergoing one myself than I would have 8 years ago. I think in the end she was confronted with severe discomfort that she never could have imagined, but she was still very clear. Even at that point, even though her hematocrit was low and she had limited oxygen carrying capacity, Ms.
LF was still working within her general framework. This determination focused primarily on three Bible passages Genesis ; Leviticus ; and Acts , which forbid the ingestion of blood [ 1 — 3 ]. In , the WBTS slightly altered its policy on blood. Other components such as albumin, fibrin, bone marrow, stem cells, dextrans, and oxygen carrying blood substitutes are more acceptable. The WBTS leaves decisions about accepting these components to the discretion of individual conscience [ 1 , 5 , 6 ]. One technique, cell-saver autotransfusion, involves salvaging lost blood from the surgical field, cleaning it, and returning it to the patient.
Other techniques to address blood loss include hormonal suppression of menstrual cycles, limited phlebotomy, and stimulation of blood component production by agents such as erythropoietin [ 7 ]. While treating any patient with leukemia involves a balance between treating the disease and avoiding treatment toxicity, this balance becomes much more tenuous for patients with leukemia who refuse blood products.
All- trans retinoic acid combined with arsenic trioxide has been used with minimal hematological toxicity for patients with acute promyelocytic leukemia [ 9 ].
Some have advocated using larger initial doses [ 10 ]. Consistently, courts have upheld the rights of competent adults to refuse lifesaving treatment [ 11 — 13 ]. The case of Karen Quinlan was pivotal in addressing the issue of care refusal. At the time of the case, Quinlan had been in a vegetative state since , and her father wished to withdraw artificial ventilation.
Convinced by the evidence presented that Quinlan herself would have chosen to discontinue treatment, the U.
Faith, Identity, and Leukemia: When Blood Products are Not an Option
Supreme Court ruled in favor of withdrawing ventilatory support [ 14 ]. The case of Nancy Cruzan further addressed the issue of surrogate care refusal on behalf of an incompetent adult. As a result of severe head injuries following a car accident, Cruzan had entered a persistent vegetative state with no signs of significant cognitive function. The case of Norwood Hospital v.
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Munoz addressed this exception. The hospital staff was able to stop her bleeding but felt that she would probably die without a blood transfusion if she began to bleed again. Despite the issue being moot in her case, the court ruled that she had been legally justified in refusing blood transfusions but that she would not have been justified if her death would have led to the abandonment of her son [ 16 ].
Smokers, for example, are not held accountable for health care costs related to their smoking. Bovine hemoglobin transfusions were first attempted in the s but with little success. Patients developed anaphylactic shock, renal toxicity, and hypertension [ 18 ]. Bovine hemoglobin has also been shown to have both vasoconstrictive and immunosuppressive effects in animal models [ 18 ].
Recently, ultrafiltration and purification techniques have significantly decreased such side effects, making hemoglobin transfusion possible. Like human hemoglobin, bovine hemoglobin contains two alpha and two beta subunits, each of which has the capacity to carry one oxygen molecule. When outside of erythrocytes, hemoglobin disassociates into 16 Kd monomers and 32 Kd dimers, which are filtered by the kidney and result in renal toxicity [ 18 ]. This distinction makes them a matter of conscience [ 3 , 6 ].
However, there is some question as to whether or not animal-derived products like free bovine hemoglobin are safe from a public heath standpoint [ 22 ]. Concerns have been raised about whether animal-derived blood products could potentially lead to human infection by prions. While there have been no firm reports of this type of contamination, more research is needed to determine the potential risk of such transmission [ 22 ]. The Supreme Court addressed this issue in Prince v. There has also been a call within the medical community to give adolescent patients more control over their care in situations where treatment is potentially lifesaving but also prolonged and risky [ 25 ].
Many additional challenges and questions arise in dealing with the families of patients who refuse potentially lifesaving treatment. Legally, a competent adult patient has full authority to refuse treatment, independent of what his or her family may believe or want. In her ethnography, The Spirit Catches You and You Fall Down, Anne Fadiman demonstrated how family involvement becomes even more significant when parents are refusing medical care on behalf of their child [ 28 ]. Fadiman described a series of conflicts between the parents of Lia , a young Hmong girl diagnosed with a seizure disorder, and caregivers at the county hospital in California where Lia was often admitted to the emergency room.
They began giving Lia less than the prescribed doses of her antiepileptic medications [ 28 ]. They eventually did give Lia the prescribed doses of her medication but only after a social worker gained their trust. When refusal of care involves a minor, treatment decisions become even more charged for patients, families, and caregivers.
Acute Leukemia Clinical Presentation
In addition to the emotions associated with losing any patient, situations in which patients refuse lifesaving treatments involve an undercurrent of issues—a disordering of caregiver roles and a clash of belief systems. One mother of five children died from an internal hemorrhage that followed a Cesarean section. Both the patient and her husband refused the use of blood products in her care, and at one point her husband and brother-in-law physically prevented the attending obstetrician from giving her a blood transfusion.
One case was reported in which a woman made a personal decision to completely refuse conventional therapy for her breast cancer. Conflicts emerge when patients refuse lifesaving treatment. While balancing beneficence and nonmaleficence, the most good for the least harm, caregivers must also respect autonomy and justice. Suddenly, giving a blood transfusion, a routine act of beneficence, has become an act of maleficence for the patient in question.
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If one considers only her physical body, the answer is yes. However, if one considers the person that Ms. LF saw and understood herself to be, the answer is no. LF knew that her physical body would deteriorate and that she would likely suffer. Yet she chose to go forward with chemotherapy in the absence of blood product support.
How she lived was more important than whether she lived. Cases like that of Ms. LF may seem to fundamentally conflict with caregiver roles and responsibilities. However, though they complicate care, they also prompt caregivers to expand their compassion for patients. As caregivers, we agree to treat people, not just bodies.
https://alirethda.ga We have to respect the way that those people see themselves. In the end, it is important to acknowledge the complicated emotions evoked by such cases, examine why these situations so greatly affect us, and explore how they might help us to redefine our own understandings of compassionate care.