The patient was a 79‐year‐old male Jehovah's Witness who had been newly diagnosed with vasculitis and was near the end of life and requiring blood products. After 2 weeks of daily hemoptysis and severe dyspnea, this patient presented with acute blood loss anemia and in acute renal failure requiring intermittent hemodialysis. He was confirmed to have ANCA vasculitis and started on plasma exchange therapy. On several occasions, nephrology discussed blood transfusions, but he was clear that he did not wish transfusion of packed red blood cells under any circumstance. After developing hypoxic respiratory failure with acidosis, he was moved to the intensive care unit and nephrology again discussed blood products. He signed the consent form for blood products and was transfused 2 units of packed red blood cells. He briefly recovered, received an additional 2 units, and stabilized. He was no longer hypoxic, but still severely anemic. The family and patient voiced they would like to stop additional transfusions, but his signed consent form was never made inactive. On the same evening, he was intubated for hypoxic respiratory failure in the setting of alveolar hemorrhage. At this time, nephrology stated that with continued plasma exchange and blood products, his vasculitis might be reversible and his case might not be fatal; however, the family stated that the patient “has been through too much,” would not wish for additional transfusions, and was considering transition to comfort care if the degree of his anemia was not survivable. He was stabilized without further blood transfusions, but remained in critical condition. After daily awakening, he was extubated to a 100% nonrebreather and demonstrated capacity. He was calm and voiced his regret over accepting blood transfusions. He voiced his preference to forgo further aggressive curative treatment if these measures included blood transfusions. Comfort measures were most consistent with his wishes and he died less than twelve hours later.
Patient autonomy is frequently misunderstood by a hospitalist, especially when caring for a patient we have just met and who is acutely ill. Although we must be honest with a patient about our recommendations, we must do so without coercion. We must realize that acute illness impairs the ability to make an informed decision. What seems like a moment of clarity may be a moment of panic in which a patient's agency is lost. In addition, respect for patient autonomy goes far beyond the respect for negative autonomy, in which we adopt a mentality of removing ourselves completely from some of the largest and most complex decisions our patients may make.
We must understand the aspects of positive and negative autonomy as it affects our role as a hospitalist. We must recognize the importance of clear advance directives. We must recognize our role in a medically complex patient when specialists may disagree with our course of treatment.