Jehovah's Witness with Necrotizing Fasciitis: Consent and Bloodless Surgery
A 58-year-old retired teacher, a Jehovah's Witness, is admitted with a 36-hour history of rapidly spreading pain and swelling of the right forearm and hand after a rose-thorn injury. She is alert and oriented, GCS 15, and has an executed advance directive refusing all blood products, including red cells, platelets, plasma, and cell salvage. Temperature is 38.9 °C, HR 124, BP 92/55 mmHg, Hb 82 g/L, platelets 88 × 10^9/L, creatinine 210 µmol/L, lactate 3.8 mmol/L, and LRINEC score 9. The hand is dusky with bullae and absent sensation; the forearm is tense. The anaesthetist says the risk of major blood loss and death is high and asks you to get consent for blood. The patient says: Do the surgery, but no blood. The hospital has no ethics committee available until the morning.
1. How would you assess capacity and obtain consent in this situation?
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She has capacity: she is alert, oriented, understands the consequences, and can communicate a consistent choice. Capacity is decision-specific, and the fact that the decision may lead to death does not make her incompetent. The emergency exception does not apply because there is no lack of consent - she has refused blood products. I would explore her understanding, explain that surgery can be performed without transfusion, and document the discussion in her own words. Her advance directive remains valid if she later loses capacity. I would not ask her family to overrule her unless she specifically authorizes family involvement. Involve a second senior clinician and the hospital ethics committee when available. Proceed with urgent debridement on the basis of her consent for surgery, accepting that transfusion will not be given even if her haemoglobin falls.
2. What blood-conservation strategy would you use for the urgent debridement and possible amputation?
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Plan a damage-control operation. Use a tourniquet for the limb, perform staged debridement rather than attempting definitive reconstruction at the first operation, and achieve meticulous haemostasis with cautery and topical haemostats. Give tranexamic acid, keep the patient warm, and avoid unnecessary blood sampling by using paediatric tubes and batching tests. Preoperatively, if time allows, give iron and erythropoietin, and optimize nutrition. Intraoperatively, accept a lower haemoglobin than usual and focus on perfusion, lactate clearance, and urine output rather than a numeric transfusion trigger. Cell salvage is refused, so do not use it. Be prepared to return to theatre for further debridement rather than performing a prolonged single operation. Discuss the possibility of major amputation and death with the patient while she is capacitated, and document her consent for surgery without transfusion.
3. How would you manage the conflict with the anaesthetist and document the case?
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I would acknowledge the anaesthetist's concern, explain that the patient has capacity and has refused blood products, and clarify that the goal is to provide the safest possible bloodless surgery rather than to obtain a transfusion. Convene a senior surgeon, senior anaesthetist, and nursing lead; involve the ethics committee in the morning and document the discussion. Do not coerce the patient or threaten to withdraw care. If a clinician is unwilling to proceed, arrange an alternative anaesthetist or transfer without abandoning the patient. Document her capacity assessment, the specific risks discussed, the advance directive, the blood-conservation measures, and the team's decision. After surgery, continue to respect the directive even if she loses capacity; the advance directive remains binding. Review the case through the hospital's clinical governance process to improve future management.