Jehovah's Witness Patients
Background
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Traditionally, orthodox Jehovah’s Witnesses won’t accept homologous or autologous whole blood, pRBCs, plasma, platelets & WBCs, even when necessary to prevent morbidity/mortality
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Refusal is based on religious beliefs deriving from strict literal interpretation of passages in the Bible forbidding the “eating” of blood
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Belief that eternal life may be forfeited if they do not exactly follow biblical commands
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Usually refused
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Whole blood
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RBCs
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Platelets
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FFP
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Cryoprecipitated antihemophilic factor
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Granulocytes
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Fibrin glue/sealant
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Predeposited autologous blood/components
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Usually accepted
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Normovolemic hemodilution*
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Intraoperative RBC salvage*
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Erythropoietin (albumin-free)
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Hemodialysis**
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Heart-lung equipment**
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*Usually accepted if patient remains in continuous contact with blood
**If non-blood prime used
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Individual Decision (according to the individual’s preference)
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Albumin
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Immune globulins
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Factor concentrates
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Organ & tissue transplants
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Considerations
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Need for preoperative hemoglobin optimization & perioperative blood conservation
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Legal issues
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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
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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
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In certain pediatric cases, the child may be made a ward of the court in order to administer clinically necessary blood transfusions
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Informed consent
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Must outline risks & benefits of receiving or refusing transfusions to the individual patient in their clinical situation
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Discuss alternatives to transfusion (may include transferring patient to another facility with more experience)
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Determine specifically which blood products/procedures the patient will accept & refuse
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If necessary, follow appropriate procedures to obtain court intervention (ex pediatric patients, patients with dementia, comatose, etc)
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Conflicts
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Conflict between beneficence & autonomy, where autonomy is generally given precedence over beneficence
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Physicians are ordinarily taught to preserve life, yet they must also respect a competent adult patient's right to refuse treatment
Management
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Optimize preop hemoglobin
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Enhance RBC production
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Iron supplementation if deficient
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Oral in divided doses
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IV if short time before surgery, intolerance to po Fe, or GI absorption problems
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Folate and/or vitamin B12 supplementation if deficient
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Erythropoietin
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If anemia of renal/chronic disease
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Minimize iatrogenic blood loss
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Avoid unnecessary testing
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Minimize test sample volume (ex pediatric tubes)
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Minimize intraop blood loss
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Meticulous surgical technique
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Regional anesthesia
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Maintain normothermia, physiologic pH
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Intraoperative cell salvage
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Normovolemic hemodilution
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Ensure hemostasis
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Antifibrinolytic agents (tranexamic acid, aprotinin, etc)
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Fibrinogen concentrate (if acceptable to patient)
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Desmopressin
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Prothrombin complex concentrates (where appropriate)
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Recombinant Factor VIIa (controversial)
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Maintain circulating blood volume
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Crystalloid
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Synthetic colloid
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In Pregnancy
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Epidural blood patch may be acceptable if blood remains in constant connection to patient (i.e. injecting syringe is connected to vein via tube)