What role should clinical evidence play in managing a Jehovah's Witness patient with a contained splenic rupture who refuses blood transfusion?

Management of a Jehovah's Witness Patient with Contained Splenic Rupture

Clinical evidence should guide the decision to pursue non-operative management with angioembolization as the primary approach for this hemodynamically stable Jehovah's Witness patient with a contained splenic rupture, while respecting her autonomous refusal of blood products.

Assessment of the Clinical Situation

The case presents several key considerations:

• 18-year-old female with contained splenic rupture following MVA
• Currently hemodynamically stable with decision-making capacity
• Religious refusal of blood transfusion (Jehovah's Witness)
• Surgeon's unwillingness to operate without transfusion capability

Evidence-Based Management Approach

Step 1: Determine Appropriateness of Non-Operative Management (NOM)

Current guidelines strongly support NOM for hemodynamically stable patients with splenic injuries:

• The WSES guidelines recommend NOM for all hemodynamically stable patients with splenic trauma, regardless of grade 1
• Up to 90% of patients with splenic injury can be treated non-operatively, with success rates exceeding 80% 1
• The patient's current stability makes her an excellent candidate for NOM

Step 2: Consider Angiography/Angioembolization (AG/AE)

For contained splenic rupture, angioembolization should be considered:

• AG/AE should be considered in all hemodynamically stable patients with WSES grade III lesions, regardless of the presence of contrast blush (Grade of Recommendation 1B) 1
• AG/AE could be considered in patients undergoing NOM who are hemodynamically stable but show signs of persistent hemorrhage 1

Step 3: Implement Blood Conservation Strategies

For this Jehovah's Witness patient, implement blood conservation strategies:

• Patient Blood Management (PBM) principles should be applied to optimize hemoglobin, minimize blood loss, and optimize hemostasis 2
• Consider pharmacologic hemostatic agents if appropriate
• Employ point-of-care testing to guide management 2

Step 4: Prepare for Possible Deterioration

If the patient becomes hemodynamically unstable:

• Operative management should be performed in patients with hemodynamic instability (GoR 2A) 1
• Attempt splenic preservation (at least partial) whenever possible (GoR 2B) 1
• In the absence of transfusion capability, cell salvage techniques may be considered if acceptable to the patient

Ethical and Legal Considerations

1. Respect for Autonomy: The patient has decision-making capacity and her refusal of blood products must be respected

2. Beneficence: The clinical evidence supports NOM with angioembolization as having good outcomes while respecting her wishes

3. Non-maleficence: Forcing transfusion against her will would constitute battery and violate her religious beliefs

4. Justice: The surgeon's personal moral disagreement should not prevent the patient from receiving appropriate care aligned with clinical evidence

Implementation Plan

1. Immediate Actions:

   • Stabilize the patient and continue close monitoring
   • Consult interventional radiology for angioembolization
   • Document the patient's informed refusal of blood products

2. Communication Strategy:

   • Explain to the refusing surgeon that clinical evidence supports NOM with angioembolization
   • Engage another surgeon willing to respect the patient's wishes while providing evidence-based care
   • Maintain transparent communication with the patient about risks, benefits, and alternatives

3. Monitoring Protocol:

   • Implement intensive monitoring as recommended for NOM (GoR 1C) 1
   • Clinical and laboratory observation with bed rest is the cornerstone of follow-up for the first 48-72 hours 1
   • Consider repeat CT scan during admission if clinical deterioration occurs 1

Pitfalls and Caveats

• Survivorship Bias: Be aware that some evidence on transfusion strategies may be affected by survivorship bias 1

• Deterioration Risk: NOM failure rates for splenic trauma range from 2-5%, with most failures occurring within the first week 1

• Ethical Conflicts: When surgeon preferences conflict with patient autonomy, the department head must prioritize evidence-based care that respects patient rights

• Documentation: Ensure thorough documentation of the patient's informed refusal and the clinical reasoning for management decisions

By following this evidence-based approach, you can provide optimal care for this patient while respecting her religious beliefs and autonomy, even in the face of surgeon reluctance.