Jehovah's Witness Patients 

 

 

Background

 

  • Traditionally, orthodox Jehovah’s Witnesses won’t accept homologous or autologous whole blood, pRBCs, plasma, platelets & WBCs, even when necessary to prevent morbidity/mortality

  • Refusal is based on religious beliefs deriving from strict literal interpretation of passages in the Bible forbidding the “eating” of blood

  • Belief that eternal life may be forfeited if they do not exactly follow biblical commands

  • Usually refused

    • Whole blood

    • RBCs

    • Platelets

    • FFP

    • Cryoprecipitated antihemophilic factor

    • Granulocytes

    • Fibrin glue/sealant

    • Predeposited autologous blood/components

  • Usually accepted

    • Normovolemic hemodilution*

    • Intraoperative RBC salvage*

    • Erythropoietin (albumin-free)

    • Hemodialysis**

    • Heart-lung equipment**

*Usually accepted if patient remains in continuous contact with blood

**If non-blood prime used

  • Individual Decision (according to the individual’s preference)

    • Albumin

    • Immune globulins

    • Factor concentrates

    • Organ & tissue transplants

 

 

Considerations

 

  • Need for preoperative hemoglobin optimization & perioperative blood conservation 

  • Legal issues

    • A patient's legal right to refuse or consent to treatment is based on common law & is therefore is constantly evolving as new cases are decided

    • Clinicians should not administer emergency treatment without consent if they have reason to believe that the patient would refuse such treatment if he or she were capable

    • In certain pediatric cases, the child may be made a ward of the court in order to administer clinically necessary blood transfusions

  • Informed consent

    • Must outline risks & benefits of receiving or refusing transfusions to the individual patient in their clinical situation

    • Discuss alternatives to transfusion (may include transferring patient to another facility with more experience)

    • Determine specifically which blood products/procedures the patient will accept & refuse

    • If necessary, follow appropriate procedures to obtain court intervention (ex pediatric patients, patients with dementia, comatose, etc)

 

 

Conflicts 

 

  • Conflict between beneficence & autonomy, where autonomy is generally given precedence over beneficence

  • Physicians are ordinarily taught to preserve life, yet they must also respect a competent adult patient's right to refuse treatment

 

 

Management

 

  • Optimize preop hemoglobin 

    • Enhance RBC production

      • Iron supplementation if deficient

        • Oral in divided doses

        • IV if short time before surgery, intolerance to po Fe, or GI absorption problems

      • Folate and/or vitamin B12 supplementation if deficient

      • Erythropoietin

        • If anemia of renal/chronic disease

  • Minimize iatrogenic blood loss

    • Avoid unnecessary testing

    • Minimize test sample volume (ex pediatric tubes)

  • Minimize intraop blood loss

    • Meticulous surgical technique

    • Regional anesthesia

    • Maintain normothermia, physiologic pH

    • Intraoperative cell salvage

    • Normovolemic hemodilution

  • Ensure hemostasis 

    • Antifibrinolytic agents (tranexamic acid, aprotinin, etc)

    • Fibrinogen concentrate (if acceptable to patient)

    • Desmopressin

    • Prothrombin complex concentrates (where appropriate)

    • Recombinant Factor VIIa (controversial)

  • Maintain circulating blood volume

    • Crystalloid

    • Synthetic colloid

 

 

In Pregnancy

 

  • Epidural blood patch may be acceptable if blood remains in constant connection to patient (i.e. injecting syringe is connected to vein via tube)

 

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