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Am Fam Physician. 2024;109(1):online

Author disclosure: No relevant financial relationships.

Case Scenario

A 33-year-old woman presents with symptomatic anemia. She reports a long history of abnormal uterine bleeding and is currently menstruating. On admission, her blood pressure is 105/90 mm Hg, and her heart rate is 113 beats per minute. She reports lightheadedness when standing and dyspnea on exertion. Her hemoglobin (Hb) is 4.9 g per dL (49.0 g per L), with a mean corpuscular volume of 61.0 μm3 (61.0 fL), which indicates severe iron deficiency. I recommend transfusion of two units of packed red blood cells; however, she tells me that she and her husband are practicing Jehovah's Witnesses, and she provides a blood-refusal advance directive card.

What is my role as a physician when a patient refuses a potentially lifesaving blood transfusion? Are there any circumstances in which physicians have an ethical responsibility to prioritize lifesaving treatment over the requests of a patient or their family members?


Critically anemic patients who refuse blood transfusions have an inverse relationship between Hb levels and morbidity and mortality, particularly for Hb levels less than 5.0 g per dL (50.0 g per L).13 For every 1 g per dL (10.0 g per L) drop in Hb below 8 g per dL (80.0 g per L), the risk of death increases 2.5-fold.4 Blood transfusions are a foundational component of treating severe anemia and are considered a lifesaving therapy.5 This makes caring for patients with severe anemia who refuse blood transfusions challenging. Physicians are bound by the four principles of medical ethics: autonomy, beneficence, nonmaleficence, and justice.6 To honor a patient's autonomous decision, a physician may face violating the other principles they have sworn to uphold. Respecting a patient's autonomy generally outweighs the other principles when treatment is refused.7 Importantly, declining a specific treatment modality does not imply refusal of all medical care and should not require patients to sign documentation of declining treatment against medical advice.5

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at

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