Attempt to defy Jehovah’s Witness strands a hospital
A hospital that agreed to perform a liver transplant on a Jehovah’s Witness without using blood products was caught in the middle of a messy legal skirmish when the husband tried to circumvent the patient’s wishes and her written declarations.
An attorney involved in the case cautions risk managers that similar circumstances could arise when clinicians get too emotionally involved in cases and try to thwart valid legal documents. In some situations, he says, such actions could leave hospitals vulnerable to serious charges of misconduct, to which juries would be unsympathetic.
Donald T. Ridley, JD, is the New York attorney who represented the Jehovah’s Witness church elder who served as the durable power of attorney (DPA) agent for the patient, 34-year-old Maria Duran. She lived in Staten Island, NY, but sought treatment at the University of Pittsburgh Medical Center (UPMC) in 1997 because the hospital had a reputation for working well with Jehovah’s Witness patients. Maria Duran was a devout Jehovah’s Witness and would not accept any blood products, but her husband, Lionel Duran, was not and neither were her two teenage children.
Patient put wishes in writing
Ridley says Maria Duran made her wishes clear throughout her treatment at UPMC and her physicians understood that she would not accept any blood products. She executed a health care DPA form and appointed an elder from the local Jehovah’s Witness congregation in Pittsburgh as her health care agent. Maria and Lionel Duran both lived with the church elder during their stay in Pittsburgh for the procedure.
The DPA form explicitly stated that Maria Duran would accept no blood of any type, not even her own stored blood, and it went on to say that "Family, relatives, or friends may disagree with my religious beliefs and with my wishes expressed herein. However their agreement is legally and ethically irrelevant because it is my subjective choice that controls. Any such disagreement should in no way be construed as creating ambiguity or doubt about the strength or substance of my wishes." The hospital did not challenge the DPA and agreed to treat her under those conditions.
When an organ became available, Maria Duran underwent the transplant surgery at UPMC. Her body rejected the organ, but she never regained consciousness from the procedure. Her doctors went to her appointed DPA agent for permission to perform a second transplant. He consented and a second liver was transplanted a week later. Her body rejected the second transplant and she remained unconscious.
Maria Duran’s doctors determined that she was in urgent need of transfusions, but did not ask the DPA agent for permission. Instead, the husband went to court to seek an emergency order appointing him guardian over his wife, which would usurp the DPA. Ridley says it is unclear how the husband came to take the legal action, but he suspects the hospital staff and physicians helped him.
"The staff knew the DPA was there. They had consulted him already and he was around the whole time," Ridley says. "He told me he overheard a hospital employee tell the husband they could help him get around the DPA. It seems to me the hospital was working with the husband and some other family members who wanted to get around the DPA and have him appointed guardian."
Court appoints husband as legal guardian
The risk manager at UPMC did not return Healthcare Risk Management’s calls seeking comment. Ridley says the hospital denied orchestrating the court action. Hospital representatives said in court that UPMC was a third party waiting for instructions. But he says he suspects the hospital suggested the legal maneuver and put the husband in touch with a local attorney.
The DPA was in the hospital for long stretches and well known to the treating staff, but Ridley says he was never notified of the court hearing. The court accepted the husband’s argument that an emergency order was necessary to save his wife’s life and appointed him emergency legal guardian. He authorized the blood transfusions and Maria Duran received several over three weeks. She died without ever regaining consciousness.
Despite her death, the DPA agent filed suit to appeal the lower court’s decision granting the husband legal guardianship. The Superior Court of Pennsylvania unanimously reversed the lower court’s order.1 In its opinion, the court agreed that "the trial court violated Maria Duran’s common law and constitutional rights when it appointed an emergency guardian to consent to a blood transfusion on [her] behalf . . . in spite of her religious beliefs and prior directives." The Superior Court went on to say, "when a patient has executed a DPA and named a personal representative, that choice is given paramount importance. Maria was not in need of a guardian. When the very situation contemplated by Maria’s DPA arose, the court should have given effect to Maria’s unequivocal directions. . . . The appointment of Lionel Duran as guardian for the express purpose of consenting to a blood transfusion contradicted Maria’s clear and unequivocal directions. To hold differently would devitalize personal health care directives and devalue the common law right to personal autonomy."
Results could be worse for hospital next time
Ridley is sympathetic to the husband and the hospital staff who wanted to help Maria Duran live, but he says the Superior Court was adamant that the DPA was valid and should have stood. The hospital should have educated its staff better about working with a DPA and the difficulty of adhering to it once the patient is unconscious and in peril.
"From an ethical standpoint, it was almost unconscionable what was going on here," Ridley says. "I don’t doubt they were trying to help the patient, but this shouldn’t have happened. There were two lawyers and three judges who thought this was just a fine thing to do, but that is simplistic thinking, a domineering way of thinking to say that they can override her religious beliefs."
In this case, Ridley says it does not appear the hospital is vulnerable to any legal or civil consequences for ignoring the DPA. Even if Maria Duran had survived and was angry that she received blood transfusions, she probably would not have a case for battery against UPMC because it was operating under a valid court order when it provided the blood, he says. But he still suggests that hospitals are taking a huge risk by circumventing a legal document they don’t like.
"It would be a novel claim, but I think it could be a breach of fiduciary duty if you could show that the hospital actively encouraged or supported this kind of thing," he says. "You could say they went against their word when they agreed to provide care under these conditions. I’m not sure any provider would want this kind of messy story in front of a jury or in the public eye. When the DPA is so clear, I don’t think there would be much sympathy for the provider, no matter how good their intentions. I could see a jury getting upset."
Conversely, Ridley says he thinks the hospital would not be exposed to liability if it followed a properly executed, valid DPA and the patient died as a consequence. He wonders if the hospital encouraged the legal maneuver because it feared a lawsuit from family members who disagreed vehemently with Maria Duran’s wishes. Ridley says he can’t understand why the first court granted the request for legal guardianship, except to suppose that everyone fell prey to the emotion of the moment. He predicts that any such action would never make it past an appellate court.
"The lasting effect of this could be that people don’t take the DPA seriously and providers will think they can go around them whenever they disagree. Or it could be a wake-up call so you go out and see what your doctors and nurses are actually doing when confronted with these situations," Ridley says. "You have to respect the patient’s clear instructions. Otherwise, do you survey the family members on every thing you do? Do you say the patient wants a heart bypass but then you go out and take a show of hands from the family?"
Reference
1. In re Duran, No. 805 WDA 2000 (Pa. Super. Ct. Feb. 21, 2001).
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content