Herbert showed up unannounced on my patient list one morning. He had casually dropped in on the ER the night before, dizzy, blacking out, unable to answer any questions. He had rheumatoid arthritis, and had been taking anti-inflammatories for decades. All of that medication had probably eaten a hole in his stomach wall, and Herbert was slowly bleeding to death. Or maybe not so slowly. That is the problem with intestinal bleeds – they cannot be seen, so the rate of blood loss is only a matter of conjecture.
The ER doc checked Herbert’s blood count before commending him to my inpatient service, and it was low, bad low, hanging-by-a-thread low. Since Herbert was almost to the point of unresponsiveness by the time the labs got back, the ER doc had to ask Herbert’s wife permission for a blood transfusion.
“No,” his wife answered. “We are Jehovah’s Witnesses.”
Jehovah’s Witnesses. Now, I have a faith of my own and I try to be as tolerant of others’ beliefs as I possibly can, but it tests the patience of Job not to exhibit at least a fig’s leaf of consternation about religious groups that refuse transfusions. The problem is that a Jehovah’s Witness will typically assent to any kind of medical treatment except blood transfusions. This singular restriction has the potential to become the nightmare of convergence: a patient who will let you use every trick in the book to keep him from crossing the threshold into the hereafter except the exact treatment most likely to make a major difference.
This difficult situation brought to mind my pediatric residency days at Children’s Hospital in New Orleans. Every once in a long while we would get a child whose parents refused transfusion. Some of these kids were getting chemotherapy for leukemia. It was an impossible situation, and usually the attending doctors would resort to petitioning a judge for a court order to force the transfusion. The court order was usually granted. In the U.S., doctors can get a court mandate for medical treatment for a child if the treatment requested is emergent and life-saving.
The surprising thing is that many of the parents of these children would take the court order in stride. Though they opposed the transfusions morally, usually they were scared to death and relieved when someone else took on the responsibility of treatment. The court order forced them into a happy, if uncomfortable, medium. They could avoid the guilt of having permitted the death of their child, and yet they could answer their God and their pastor with “the transfusion was forced on us; we had no choice.”
Unfortunately, the law does not work that way for adults. We have to abide by the patient’s refusal in almost all circumstances, the lone exception being a patient who is not mentally competent and has no next-of-kin.
Herbert ended up in the ICU. He might have gone to the regular floor if we could have ordered a transfusion from the very first, but this was not to be. His serum hemoglobin, a measurement of the amount of blood in his body, stood at 7.2. Normal is 15, and anything below 8.0 is considered serious.
I gave Herbert the once-over in the ICU, and asked a stomach specialist to take a look. The stomach man dropped a scope down his throat the next morning, found a bleeding ulcer in the proximal small intestine and cauterized it. Herbert stabilized a bit, but because we couldn’t give him blood he was very weak. He held out for a few days and then developed pneumonia. He had probably aspirated (breathed in) some of his own secretions when he initially collapsed, and it had taken a few days for the infection to take hold.
The lung infection made its way into the circulation and before long Herbert’s blood pressure had dropped dangerously low. He was placed on a respirator and we started drips to prop up the pressure. Again, I try not to look demeaningly upon any person’s faith, but this no-transfusion ethos had maneuvered us into an absurd situation. We were applying maximal life support measures but still were forbidden to address the underlying problem.
Back in those days I was overworked and crazy and I usually saw Herbert at about 10 at night. He was all wires and tubing. Almost everything in the room was a sterile white including his gown and my lab coat and the only contrast was the shadow from the 24-hour fluorescent light. With every conceivable tube and wire coming out of him he looked like a swamp creature rising from the water in a black-and-white movie.
The swamp creature would not die. He floundered on, his hemoglobin lurking just below 8.0. Most of the time he was unresponsive. We revisited the issue of the transfusion with his wife several times, but the answer was always no. Three weeks shuffled by, nothing changing.
A rumor circulated among the ICU staff that the wife was a far more committed Jehovah’s Witness than her husband. A visiting family member suggested that Herbert would have consented to the transfusion, that it was his wife who was against it. Unfortunately, the way the law worked, this fact meant little. For all practical purposes, the word of the next-of-kin was the rule.
In theory, though, the rumor suggested that Herbert’s wife was violating the intent of the law. Ethically, a person who serves as the decision maker is supposed to make the decision as the incapacitated person’s proxy – in other words, Herbert’s wife was supposed make decisions according to her husband’s wishes as best as she knew them, and not according to her own. In my personal experience, I have often felt that family members fail to make that distinction.
Things went along like that, in a hopeless standoff, and I began to despair that three weeks of work to keep Herbert with us was amounting to nothing more than a prolonged, expensive form of death by torture. Until a break unexpectedly came.
One late night I came by and noticed that Herbert’s eyes were open. He was still on the respirator and couldn’t talk with the tube in his throat, but when I questioned him, he nodded yes and no appropriately. A lucid moment! I decided to test the rumor that Herbert was not a Jehovah’s Witness right then.
I introduced myself as his doctor and then explained to him that he was severely anemic. That he was in intensive care and near dying. That I felt the only way he could be saved was with a blood transfusion.
“Your wife has declined to let us give you a transfusion,” I said. “But the decision is not really hers, it is yours. If you want one, I will give it.”
He nodded yes.
“You are certain? You understand what I am asking? I want to give you blood.”
He nodded yes again.
To make certain, I called Herbert’s nurse, Todd, into the room. He was the perfect nurse for the case. I knew Todd as a very pragmatic, hard-edged personality. It could have been the effect of many years of working in an inner city hospital, but I think it was just him. Todd was always good for a rant about patients that didn’t take care of themselves at home and then would come into the ER falling apart. He hated the money wasted in ICUs. If Herbert was saying yes to a transfusion, I knew Todd would have the blood running in thirty minutes. He, like me, was tired of the waste and the stalemate. If I decided to go full speed ahead against the wishes of Herbert’s wife, there would be no resistance from Todd.
Todd had spent many years working with the elderly, who are frequently hard of hearing. His habit was to shout at poorly responsive patients. I am certain he thundered in poor Herbert’s ears. “WE WANT TO GIVE YOU BLOOD! ARE YOU CONSENTING TO A BLOOD TRANFUSION RIGHT NOW! IF YOU DON’T GET IT YOU COULD DIE!”
Herbert nodded again. There was no question in my mind he was saying yes.
We stuffed the blood into him, three units by 7 am. True to his word, Todd got the transfusion done before anyone could come in the next morning and say anything. Yes, we were being sneaky. But this guy had been in intensive care for the better part of a month, no doubt suffering greatly, and I had no intention of dithering if I could get him out of this deadlock.
Herbert turned around almost immediately. The blood raised his hemoglobin to over 10. In less than 24 hours he was off all his drips, and in two days he was off the ventilator and breathing on his own. The tentacles were falling off the swamp monster. There was a man inside.
I never spoke to Herbert’s wife about the transfusion. I am not even sure she knew. Herbert knew, though, and was fine with it. Which was all I needed anyway.
As soon as Herbert was off the respirator and stable, I got a call from the powers above – powers more absolute than those of Jehovah himself – Herbert’s HMO. The almighty HMO wanted Herbert moved to a network hospital now that he was stable. My hospital wanted the transfer too, because if the transfer were not made, the HMO would cut off any further payment, no matter how sick Herbert became. Since he was nowhere near out of trouble yet, this denial could cost my facility hundreds of thousands.
After a microsecond of consideration I approved the request and Herbert was gone like swamp vapor in the morning light. Just like that, the next day ICU bed 17 was empty, a fresh sheet spread tightly across it, waiting for the next Herbert.
Herbert was gone, and I never heard a word from or about him again. The only time I ever saw his name in print after that was in a letter I received from the HMO. It denied payment for the entire 4 week hospital stay because, the auditors said, the same level of care could have been delivered in “an alternative setting, such as a nursing home.”
I looked at the letter, and wished I could have had some of what they were drinking. Chivas Regal didn’t take the edge off those long stressful days like it used to.