Wednesday, July 15, 2009

Treating multiple myeloma when the patient is a Jehovah's Witness

During medical school, we're often faced with clinical case vignettes where we get to practice problem solving skills. Such cases also often involve issues surrounding medical ethics. Anytime you get a case where the patient is a Jehovah's Witness, you know you'll be dealing with something ethical (that probably involves blood transfusions).
According to Wikipedia, "Jehovah's Witnesses are not permitted to accept red cells, white cells, platelets or plasma, though they may accept fractions made from these components at their own discretion."
How do you treat a patient who has multiple myeloma if that individual requires blood transfusions but refuses? This is being discussed on Sermo by various oncology physicians. It's a very difficult situation because what is medically necessary isn't an option if the patient competently refuses that treatment. Will a combination of various anti-cancer drugs (such as Thalomid or thalidomide, Velcade or bortezomib, and Revlimid or lenalidomide) and growth factors (such as Procrit or epoetin alfa and Aranesp or darbepoetin alfa) help an individual who has progressed so far in this illness? Or, are such strategies medically futile?

I think one of the most difficult things to face is a dying patient who refuses medical care. It's more than a mental exercise. When you know that you can do something to help that person and that person is willfully refusing (it may be for a variety of reasons), that just becomes a very challenging situation. Alternative medical options may be futile. Do you try them anyways? Sometimes there are no practical options that won't endanger the patient further. You can't just walk out or abandon that type of patient. Do you suggest hospice? At what point do you discontinue futile efforts?

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