# A nurse is caring for a competent adult patient who is refusing a blood transfusion due to religious beliefs, despite having a critically low hemoglobin level of 5.2 g/dL. The patient's family is pressuring the healthcare team to override the patient's decision. What is the most appropriate nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543608  
> language: ko  
> subject: Critical Care

## 문제

A nurse is caring for a competent adult patient who is refusing a blood transfusion due to religious beliefs, despite having a critically low hemoglobin level of 5.2 g/dL. The patient's family is pressuring the healthcare team to override the patient's decision. What is the most appropriate nursing action?

## 보기

1. Convince the patient to accept the transfusion by explaining the medical risks of refusal
2. Collaborate with the family to obtain consent for the transfusion since the patient's life is at risk
3. Contact the hospital ethics committee to override the patient's religious-based refusal
4. Respect the patient's autonomous decision and explore alternative treatment options with the healthcare team **✔ 정답**

**정답: 4**

## 해설

Competent adult patients have the right to refuse treatment based on religious beliefs, and nurses must respect autonomy while exploring alternative care options. Other options violate patient self-determination.

## 심화 해설

Correct Answer: 4

Analysis of the Clinical Scenario

This question tests the ethical principle of autonomy and its application in a culturally sensitive clinical situation. The patient is a competent adult with a critically low hemoglobin of 5.2 g/dL, who is refusing a life-saving blood transfusion based on religious beliefs, a scenario commonly encountered with patients who are Jehovah's Witnesses. The family's distress and desire to override the patient's decision creates a conflict, but the legal and ethical framework is clear: a competent adult's informed refusal must be honored, even if it results in death.

Why Option 4 is the Most Appropriate Action

The most appropriate nursing action is to respect the patient's autonomous decision and collaborate with the healthcare team to explore and implement evidence-based alternative treatments. This approach upholds the core nursing ethical principles of autonomy and beneficence. Beneficence, in this context, shifts from the singular focus of administering blood to the broader duty of providing the best possible care within the patient's defined boundaries. The provided literature explicitly supports this, noting that management of acute blood loss anemia in Jehovah's Witnesses is a recognized medical challenge where "advancements have been made in pharmacologic options... as well as procedural interventions" [1]. This confirms that a robust, alternative care pathway exists and is a standard of practice, not an abandonment of care.

Critical Analysis of Incorrect Options

Option 1: Convince the patient to accept the transfusion.

This action is inappropriate and ethically problematic. It violates the principle of autonomy by attempting to coerce a patient into a decision against their deeply held religious convictions. While ensuring informed consent is a nursing responsibility, once a competent patient demonstrates a clear understanding of the risks and consequences of refusal, persistent persuasion becomes a form of undue influence. Cultural competence, as highlighted in the literature, requires moving beyond one's own value system to acknowledge and respect patient differences . The goal is not to change the patient's belief to align with the medical team's view of what is best.

Option 2: Collaborate with the family to obtain consent.

This action is legally and ethically incorrect. For a competent adult, the locus of decision-making authority rests solely with the patient, not the family. Obtaining consent from a family member to override a competent patient's explicit refusal constitutes battery. While family involvement is a cornerstone of patient-centered care, it cannot supersede the patient's own directive. The ethical dilemma here is not a family-vs.-patient decision, but a patient-vs.-disease challenge that requires a tailored medical approach [1].

Option 3: Contact the hospital ethics committee to override the patient's refusal.

This action is based on a misunderstanding of an ethics committee's function. A clinical ethics committee (CEC) serves as a consultative body to help navigate moral challenges, clarify values, and support healthcare professionals in reaching a resolution . It does not possess the authority to "override" a competent adult's informed refusal of treatment. Such a refusal is a legal right, not a moral failing to be corrected. While consulting the ethics committee can be a supportive step for the distressed staff and family, the purpose would be to facilitate understanding and mediate conflict, not to reverse the patient's autonomous choice.

Integrating Cultural Competence into Clinical Practice

This scenario underscores the critical need for transcultural nursing skills. The literature emphasizes that caring for patients from specific cultural and religious groups, such as Jehovah's Witnesses, presents unique "ethical and legal dilemmas" that require specific awareness and knowledge . Cultural competence is not merely about knowing a list of beliefs; it is a willingness to learn about differences and acknowledge them in the planning and delivery of care . For a nurse, this means proactively seeking knowledge about acceptable bloodless medicine alternatives—such as iron replacement, erythropoiesis-stimulating agents, and tranexamic acid—and advocating for their prompt implementation [1]. This transforms a potentially adversarial situation into a collaborative therapeutic alliance where the patient feels safe and respected, and the healthcare team can fulfill its professional obligation to provide optimal care within the patient's moral framework.References (research sources)

- [1]Orthopaedic Trauma Management in the Jehovah's Witness Population.Research articleSaxena TA, Massey PA, Chauvin B. (2025) · DOI: 10.5435/jaaosglobal-d-24-00322

## 임상 시나리오

Managing Refusal of Blood TransfusionHonoring Autonomy in Critical Anemia
When a competent adult refuses a blood transfusion, the nurse's primary role is to respect the patient's autonomous decision, even if the hemoglobin is critically low (e.g., 5.2 g/dL).

Immediately shift the care plan to bloodless medicine alternatives to support oxygenation and hemostasis. This includes optimizing volume status with crystalloids, administering recombinant erythropoietin, and using intravenous iron supplementation to stimulate erythropoiesis.

For active bleeding, collaborate with the team to implement procedural interventions such as hemostatic agents, cell salvage, or targeted surgical techniques to minimize blood loss while respecting the patient's directive.

CautionNever attempt to coerce the patient or allow family members to override the decision. A signed informed refusal form is essential, but the focus must remain on providing the best possible care within the patient's defined boundaries.

## 핵심 개념

- **Autonomy** — The ethical principle that a competent individual has the right to make informed decisions about their own medical care without coercion.
- **Informed Refusal** — A competent patient's decision to decline recommended medical treatment after being fully informed of the risks, benefits, and alternatives.
- **Beneficence** — The ethical duty to act in the patient's best interest, which includes providing safe alternative care when a standard treatment is refused.
- **Competence** — A patient's legal and clinical capacity to understand their medical situation and make rational healthcare decisions.
- **Bloodless Medicine** — A range of medical and surgical techniques and pharmaceuticals used to treat patients without the use of allogeneic blood transfusions.

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