A 15-Year-Old Jehovah's Witness With a Bleeding Spleen

Three separate issues are being conflated: the minor's own wishes, the parents' refusal, and the doctor's duty to act in the child's best interests.

Assessment:

• Determine whether the boy is Gillick-competent for this decision - whether he understands the nature of the injury, the proposed treatments, the risks of refusing blood and the alternatives. His statement that he wants 'whatever keeps me alive' suggests he may be prioritising survival over the religious position, and this must be explored privately and documented.
• A minor's refusal of life-saving treatment is generally not binding, and neither is a parent's refusal where treatment is clearly in the child's best interests; courts have repeatedly authorised transfusion over parental objection in children. Local law and hospital policy determine the exact route, so involve the consultant, the hospital legal team and the ethics committee now, not after a collapse.
• Do not act covertly or deceive the parents; explain the reasoning and keep them involved in every other decision.

The immediate step is to call the consultant back to the hospital, begin the non-transfusion pathway, and start the legal escalation in parallel. Document all discussions verbatim and record who was present, because this is the part of the case most likely to be scrutinised later.

He is currently haemodynamically stable with a blush, which is the ideal window for angioembolisation - it is the single most effective intervention to avoid splenectomy and transfusion in this setting.

Strategy:

• Transfer for angioembolisation of the splenic artery branches now, with a plan for immediate splenectomy if he becomes unstable.
• Tranexamic acid 1 g followed by 1 g over 8 hours, given within 3 hours of injury.
• Cell salvage with a continuous circuit is accepted by many Jehovah's Witness patients because the blood is not stored; discuss it explicitly with the family rather than assuming.
• Permissive hypotension targeting a systolic pressure around 90 mmHg while he is alert with good urine output, and restrictive crystalloid to avoid diluting his haemoglobin.
• Erythropoietin, intravenous iron, folate and B12 to support erythropoiesis; correct any coagulopathy with fibrinogen and vitamin K where clinically indicated.
• Monitor haemoglobin, lactate and base deficit serially, with hourly observations and repeated abdominal examination; a rising lactate or falling urine output changes the plan to theatre.
• Have the splenectomy set and the theatre team ready, and book a high-dependency bed.

He is now an unstable exsanguinating patient with a grade IV splenic injury. The immediate priority is haemorrhage control; the ethical question of transfusion must be resolved in parallel rather than instead of it.

Actions:

• Call the consultant to attend and notify theatre and anaesthesia; go to laparotomy for splenectomy or splenorrhaphy if embolisation cannot be achieved immediately.
• Activate the massive haemorrhage protocol so that blood is available, and simultaneously call the legal/ethics pathway - in a life-threatening emergency involving a minor whose parents refuse consent, the accepted route is to treat in the child's best interests under the emergency doctrine or after urgent judicial/ethical authorisation, following local law.
• Continue the non-blood measures: tranexamic acid, cell salvage, warming, calcium replacement with any products given, and haemostatic agents locally.
• Document the deterioration, the discussion with the parents, the escalation, and the reason for each decision in real time.

Afterwards, disclose fully what was done and why, involve the family in the postoperative plan, and refer the case for a formal review so that the next similar case has a pathway agreed in advance rather than at the bedside.