By Ryan Pferdehirt, D.Bioethics, HEC-C

June 2022

Bioethics case study on patient nonadherence and religion.

Collin is an APRN in the ICU. Collin is part of a medical team caring for a 27-year-old male identifying patient named Xiang who sustained numerous injuries from a car accident. Xiang is stable, has full decisional capacity, but suffered extensive trauma to his leg. According to his medical team, the trauma is so severe, leg reconstruction is likely impossible, short of some miracle. They agree it is best to amputate the leg, below the knee (BKA). The medical team meets with Xiang, who is accompanied by his mother, to discuss his situation in depth.

After delivering the news, the medical team leaves, but Collin stays behind to check on Xiang and his mother. Xiang’s mother, a devout Christian, believes that Collin should “put everything in God’s hands.” “My son does not need an amputation. God will restore his leg. The doctors will see. We are praying for a miracle.” Xiang agrees emphatically with his mother, further noting his family’s bad experiences with hospitals and doctors elsewhere when healthcare had been needed. So Xiang, while expressing gratitude for the care provided here, has decided to place his trust “in a higher power.” Collin takes a moment to further underscore the complications and consequences that may arise from not having the leg amputated, including death, but it appears Xiang has made up his mind.

Confused and concerned, Collin leaves Xiang’s room. He wants to provide “the best care possible,” per the mission statement of this healthcare system, also. But what does one do when a patient decides to decline our “best care” while trusting God for miraculous healing instead? What does “care” mean in a situation like this? Time is of the essence, as Xiang’s physicians had explained to their patient. If Xiang does not consent to a BKA, his prognosis for recovery goes from excellent to uncertain, or worse. Necrosis is nearly certain for lack of sufficient blood flow to the lower leg. Despite excellent infection control measures here, sepsis will happen sooner or later, with a potentially fatal outcome. Xiang’s pain could be severe, mitigated only by deep sedation at best. This might turn out to be a horrific death of a young man, a death wholly preventable.

While imagining the worst-case scenario, Collin believes there might still be hope for negotiating a reasonable care plan. In their team huddle that afternoon, Collin conveys his worries for Xiang. He suggests that they request an ethics consultation.

What should be done?