Informed refusal

Abstract: A written birth plan encourages women to clarify desires and expectations and communicate with their providers to make a realistic plan for care during labor. Tension between health professionals and patients caused by birth plans reflects the larger problems with contemporary maternity care: conflicting beliefs about birth, what constitutes safe, effective care, and ethical issues related to informed consent and informed refusal. The focus of birth plans should be to answer three patient-focused questions: What will I do to stay confident and feel safe? What will I do to find comfort in response to my contractions? Who will support me through labor, and what will I need from them? In this article, the history and purposes of birth plans and approaches to resolving tensions will be discussed.

Abstract: Physicians face a special challenge in treating Jehovah's Witnesses. Members of this faith have deep religious convictions against accepting homologous or autologous whole blood, packed RBCs, WBCs, or platelets. Many will allow the use of (non-blood-prime) heart-lung, dialysis, or similar equipment if the extracorporeal circulation is uninterrupted. Medical personnel need not be concerned about liability, for Witnesses will take adequate legal steps to relieve liability as to their informed refusal of blood. They accept nonblood replacement fluids. Using these and other meticulous techniques, physicians are performing major surgery of all types on adult and minor Witness patients. A standard of practice for such patients has thus developed that accords with the tenet of treating the "whole person." ( JAMA 1981;246:2471-2472)

Abstract: End-of-life care of critically ill patients generally consists of two closely related practices: the withholding and withdrawal of life support, and the administration of palliative care. In the United States, the withholding or withdrawal of life support is legally justified by the principles of informed consent and informed refusal. The U.S. Supreme Court has held that competent patients may refuse any and all treatments, including those that sustain life. All states sanction such refusal by competent patients, and most states allow surrogates to refuse treatment on behalf of incompetent patients. Although some physicians use the concept of futility to unilaterally withhold or withdraw life support, the Supreme Court has not heard a futility case, and the only clear legal rule on futile treatment is the traditional malpractice test, which measures physician actions against standards of medical care. However, the Supreme Court has furnished guidelines on the administration of palliative care. By using the principle of double effect, these guidelines allow physicians to give sedative and analgesic agents to dying patients if they intend to relieve pain and suffering but not to hasten death.