This Malpractice Case Study presents a closed claim involving a general surgeon who was treating a patient that refused blood products based on his religious beliefs.
Allegation
The physician failed to timely perform surgery prior to deterioration and death.
Case Details
A 67 YOM was transferred from an inpatient rehabilitation facility to the hospital. He was four months post bowel resection with intermittent diffuse abdominal pain, decreased appetite, and constipation, with a 20-pound weight loss in four months. The CT scan was suspicious for partial small bowel obstruction versus a mass. Laboratory results reported low hemoglobin at 6.8 and normal white blood count. The patient was admitted with an order for a surgical consult.
The following day, Surgeon #1 examined the patient and reported that he was afebrile, bowel sounds were present, abdomen was soft, non-distended, and non-tender, with no guarding, rigidity, or rebound tenderness. The patient was tolerating a full liquid diet. He denied fevers, chills, nausea, or vomiting. Surgeon #1 charted that because the patient was afebrile, had normal white blood count, had no other signs of systemic infection and minimal abdominal tenderness, surgery was not needed at the time. Hemoglobin remained low. The patient reported his religion as Jehovah’s Witnesses and he refused blood products. Follow up labs and serial abdominal exams were ordered.
Over the next three days, the patient was seen by Surgeon #1 and an internist. The patient continued to tolerate a full liquid diet; he had three bowel movements and denied any pain. Hemoglobin remained low. The patient signed a refusal of blood products form. Surgeon #1 and internal medicine documented the patient had no need for acute surgical intervention. They planned for an outpatient endoscopic exam to evaluate the possible mass. The patient was instructed to follow up with Surgeon #1 at his office in two weeks. The patient was discharged back to the inpatient rehabilitation facility.
Ten days later, the patient presented to a different hospital with nausea, vomiting, and fever. The CT scan reported partial bowel obstruction and thickening suggestive of inflammatory colitis. The patient was positive for c. diff. He reported multiple loose stools in the past three days, abdominal pain and temperature of 103. The patient was admitted. Over the next ten days the patient was treated with antibiotics and seen by critical care and Surgeon #2. The patient’s hemoglobin remained critically low and lactic acid was worsening. Surgeon #2 documented multiple discussions with the patient and family that options were limited due to refusal of blood products which would allow resuscitation and surgical options. Blood products were absolutely refused. Over the next two weeks, the patient continued to decompensate, progressed into multiple organ failure and died.
Surgeon #1 was sued on the theory that timely surgical intervention at the first admission was required and would have avoided the patient’s deterioration, multiorgan failure and death. Surgeon #2 was not included in the lawsuit.
Expert Testimony
At deposition, Plaintiff’s expert testified that surgery was required at the first admission based on the CT scan results. He testified that surgery was urgent because the patient was slowly dying as evidenced by his inability to eat and loss of over 20 pounds.
The defense experts for Surgeon #1 testified that the patient did not have a surgical abdomen, and surgery was not indicated at the first admission. While exploratory surgery may have been an option, the patient’s low hemoglobin and refusal of blood products placed him at an extremely high risk.
Resolution
Surgeon #1 defended his care through three years of litigation. The plaintiff voluntarily dismissed Surgeon #1 two weeks before trial. This resulted in a successful defense because the surgeon’s clinical decision making was accurately documented. In addition, when the patient’s hemoglobin remained low, there were multiple entries of the patient’s refusal of blood products and a signed refusal placed in the chart.
Risk Reduction Strategies
Ensure that your documentation includes a complete description of your assessment and plan.
When a patient refuses recommended treatment, consider the following:
- Ensure that the patient has decision-making capacity or a legal representative who has authority to refuse treatment. If there is any question about capacity, the patient should be assessed.
- Have a complete informed refusal discussion with the patient including the risks of refusal and any alternative treatment options.
- Document the informed refusal discussion along with the patient’s reason for refusing treatment.
- Consider having the patient sign an informed refusal document.
- Revisit the informed refusal discussion if the patient’s risks of refusal are increased based on any change in condition.
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