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Management of Patients Who Refuse Blood Transfusion
CHAPTER 56
Management of Patients Who Refuse Blood Transfusion Burak Bahar, MD and Jeanne E. Hendrickson, MD A doctrine introduced in 1945 by Jehovah’s Witnesses teaches that the Bible prohibits the consumption, storage, and transfusion of human blood (Genesis 9:3, 4 and Acts 15:19, 20). The Watch Tower Bible and Tract Society of Pennsylvania have issued many doctrines since that time, citing that “blood is sacred to God,” and “even in the case of an emergency, it is not permissible to sustain life with transfused blood.” These beliefs stem from the interpretation of Biblical scriptures. Many Jehovah’s Witnesses carry medical directive “No Blood” cards, stating that blood transfusions are unacceptable. The use of blood derivatives, however, is not specifically prohibited, and the Watch Tower encourages members to personally decide whether accepting these component fractions violates the doctrine(s). Examples of potentially accepted blood product derivatives include cryoprecipitate, albumin, immunoglobulin therapy, human- derived clotting factor concentrates, and interleukins. Recombinant proteins (e.g., recombinant factor VIIa) are generally accepted by Jehovah’s Witnesses, as are blood substitutes (hemoglobin-based oxygen carriers) (Fig. 56.1). While standard transfusions are unacceptable, there are some related procedures that are not specifically prohibited. These include plasma exchange, dialysis, intraoperative blood salvage, hemodilution, blood donation strictly for the purpose of further fractionation of components, and transfusion of autologous blood as long as a continuous circuit with the patient remains. Transfusion of preoperatively donated autologous blood is, however, typically prohibited, due to the belief that blood should not be taken out of the body and stored (Table 56.1). The right of a competent adult to refuse consent for medical treatment is accepted, and documentation of refusal for transfusion should be placed in the medical record. Electronic medical record and laboratory information systems may be useful in preventing blood from being inadvertently ordered or transfused to a non-consenting patient. Worst-case scenario discussions should be held with patients who refuse blood products, and documentation to this effect should be included in the medical record; some clinicians opt to have patients sign the notes stating that these discussions were held. Forcing a non-consenting patient to receive a transfusion unwillingly can be viewed as battery, and a Jehovah’s Witness who accepts a transfusion can be spiritually cut off from a community of family and friends.
Trauma: Situations of trauma are difficult, in that medical directive cards may not be immediately available. If there is any doubt in a clinician’s mind as to the wishes of the patient or as to what is legally appropriate, it is recommended that the clinician treat per the accepted standards of care until legal documentation is available.
Transfusion Medicine and Hemostasis. https://doi.org/10.1016/B978-0-12-813726-0.00056-8 Copyright © 2019 Elsevier Inc. All rights reserved.
357
358
Burak Bahar, MD and Jeanne E. Hendrickson, MD
Unacceptable
Red cells
Oxygen therapeutics* *Products in development
Personal decision
Whole blood
White cells
Interferons* Interleukins* *Recombinant products available
Platelets
Platelet substitutes* *Products in development
Plasma
Immune globulins Clotting factor concentrate* Prothrombin complex Cryoprecipitate† Albumin‡ *Recombinant VIIa, VIII, IX available †Prepared with 0.9% sodium chloride injection (USP) diluent ‡Recombinant albumin in clinical trials
FIGURE 56.1 Blood components and fractions. (Reproduced from Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116, with permission from Elsevier.)
Pregnant Women and Children: The treatment of pregnant women and children deserves special attention. Given that minor children are not considered capable of informed consent, it is recommended that the clinician seek legal intervention in cases where the fetus or child is placed at risk by parental refusal for transfusion. Laws governing the locality in which the patient is treated determine whether a treating physician can emergently transfuse a non-consenting pregnant woman or a child, with legal experts often determining that a life-saving blood transfusion is in the best interest of the child.
Blood Management: If a patient does not allow transfusion, the treating physician should attempt to find an alternative therapy within the boundaries of the patient’s religious beliefs. Such options include blood conservation, optimizing coagulation, and use of non-blood adjunctive therapies. If time allows, adequate preoperative planning and incorporation of strategies to maximize erythropoiesis may decrease the likelihood of severe anemia intraoperatively or postoperatively. Blood conservation can also be achieved by reducing blood loss through decreased phlebotomy and meticulous surgical care, intraoperative blood salvage, and/or acute normovolemic hemodilution. Depending on what products are deemed to be acceptable by the individual patient and what the clinical situation is, coagulation may be optimized with vitamin K, cryoprecipitate, 1-deamino-8-d-arginine vasopressin (DDAVP), fibrinogen concentrates, antifibrinolytic drugs, prothrombin complex concentrates, or recombinant factor VIIa. Potential adjunctive therapies to increase RBC mass and improve oxygenation include iron, folate, vitamin B12, erythropoietin, alternative oxygen carriers, or hyperbaric oxygen. The potential complications of each of these treatments must be weighed against their potential beneficial effects. The Hospital Information Services department of the Watch Tower Society has established more than 1700 Hospital Liaison Committees worldwide to support health-care providers in their care of Jehovah’s Witnesses. These committees can be reached at 718-560-4300 and https://www.jw.org/en/medical-library/ hospital-liaison-committee-hlc-contacts/united-states/.
Blood Refusal
359
TABLE 56.1 Jehovah’s Witness Religious Position on Medical Therapy Acceptable Treatment • Most surgical and anesthesiological blood conservation measures (e.g., hemostatic surgical instruments, controlled hypotension regional anesthesia, minimally invasive surgery, meticulous surgical hemostasis) • Most diagnostic and therapeutic procedures (e.g., phlebotomy for laboratory testing, angiographic embolization) • Pharmacologic agents that do not contain blood components or fractions such as the following: • Drugs to enhance hemostasis (e.g., tranexamic acid, epsilon-aminocaproic acid, aprotinin, desmopressin, recombinant factor VIIa, conjugated estrogens) • Hematopoietic growth factors and hematinics (e.g., albumin-free erythropoietin, iron) • Recombinant products (e.g., albumin-free coagulation factors) • Synthetic oxygen therapeutics (e.g., perfluorochemicals) • Non–blood volume expanders (e.g., saline, lactated Ringer’s, hydroxyethyl starches) Personal Decision (Acceptable to Some, Declined by Others) • Blood cell salvagea (intraoperative or postoperative autotransfusion) • Acute normovolemic hemodilutiona • Intraoperative autologous blood component sequestrationa (including intraoperative plateletpheresis, preparation of fibrin gel, platelet gel, platelet-rich plasma) • Cardiopulmonary bypassb • Apheresisb • Hemodialysisb • Plasma-derived fractions (e.g., immune globulins, vaccines, albumin, cryoprecipitatec) • Hemostatic products containing blood fractions (e.g., coagulation factor concentrates, prothrombin complex concentrate, fibrin glue/sealant, hemostatic bandages containing plasma fractions, thrombin sealants) • Products containing plasma-derived blood fractions such as human serum albumin (e.g., some formulations of erythropoietin, streptokinase, G-CSF, vaccines, recombinant clotting factors, nuclear imaging products) • Products containing a blood cell–derived fraction • Epidural blood patch • Blood cell scintigraphy (e.g., radionuclide tagging for localization of bleeding) • Peripheral blood stem cell transplantation (autologous or allogeneic) • Other transplants (organ, HSC [hematopoietic stem cell], bone) Unacceptable Treatment • Transfusion of allogeneic whole blood, red blood cells, white cells, platelets, or plasma • Preoperative autologous blood donation aPatients
might request that continuity is maintained with their vascular system. not primed with allogeneic blood. cCryoprecipitate suspended in 0.9% sodium chloride injection (USP) diluent. Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116, with permission from Elsevier. bCircuits
Summary: An adult patient with decision-making capacity may defer some or all treatment modalities for themselves, which may include refusing blood products. Optimal management of patients who refuse blood transfusion requires close communication with the patient and their support network, early preoperative planning, and a thorough assessment of possible alternatives to transfusions.
360
Burak Bahar, MD and Jeanne E. Hendrickson, MD
Further Reading Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116. Booth, G. S., & Pilla, M. A. (2016). Preventing the preventable: How the blood bank laboratory information system fails to protect patients that refuse blood. Transfus Apher Sci, 55(2), 245. Jassar, A. S., Ford, P. A., Haber, H. L., Isidro, A., Swain, J. D., Bavaria, J. E., et al. (2012). Cardiac surgery in Jehovah’s Witness patients: Ten-year experience. Ann Thorac Surg, 93(1), 19–25. Lawson, T., & Ralph, C. (2015). Perioperative Jehovah’s Witnesses: A review. Br J Anaesth, 115(5), 676–687. Rogers, D. M., & Crookston, K. P. (2006). The approach to the patient who refuses blood transfusion. Transfusion, 46(9), 1471–1477. Scharman, C. D., Shatzel, J. J., Kim, E., & DeLoughery, T. G. (2017). Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol. https://doi.org/10.1002/ajh.24889. Epub 8/18/17. Spahn, D. R., & Goodnough, L. T. (2013). Alternatives to blood transfusion. Lancet, 381(9880), 1855–1865. Zeybek, B., Childress, A. M., Kilic, G. S., Phelps, J. Y., Pacheco, L. D., Carter, M. A., et al. (2016). Management of the Jehovah’s witness in obstetrics and gynecology: A comprehensive medical, ethical, and legal approach. Obstet Gynecol Surv, 71(8), 488–500.
Management of Patients Who Refuse Blood Transfusion Burak Bahar, MD and Jeanne E. Hendrickson, MD A doctrine introduced in 1945 by Jehovah’s Witnesses teaches that the Bible prohibits the consumption, storage, and transfusion of human blood (Genesis 9:3, 4 and Acts 15:19, 20). The Watch Tower Bible and Tract Society of Pennsylvania have issued many doctrines since that time, citing that “blood is sacred to God,” and “even in the case of an emergency, it is not permissible to sustain life with transfused blood.” These beliefs stem from the interpretation of Biblical scriptures. Many Jehovah’s Witnesses carry medical directive “No Blood” cards, stating that blood transfusions are unacceptable. The use of blood derivatives, however, is not specifically prohibited, and the Watch Tower encourages members to personally decide whether accepting these component fractions violates the doctrine(s). Examples of potentially accepted blood product derivatives include cryoprecipitate, albumin, immunoglobulin therapy, human- derived clotting factor concentrates, and interleukins. Recombinant proteins (e.g., recombinant factor VIIa) are generally accepted by Jehovah’s Witnesses, as are blood substitutes (hemoglobin-based oxygen carriers) (Fig. 56.1). While standard transfusions are unacceptable, there are some related procedures that are not specifically prohibited. These include plasma exchange, dialysis, intraoperative blood salvage, hemodilution, blood donation strictly for the purpose of further fractionation of components, and transfusion of autologous blood as long as a continuous circuit with the patient remains. Transfusion of preoperatively donated autologous blood is, however, typically prohibited, due to the belief that blood should not be taken out of the body and stored (Table 56.1). The right of a competent adult to refuse consent for medical treatment is accepted, and documentation of refusal for transfusion should be placed in the medical record. Electronic medical record and laboratory information systems may be useful in preventing blood from being inadvertently ordered or transfused to a non-consenting patient. Worst-case scenario discussions should be held with patients who refuse blood products, and documentation to this effect should be included in the medical record; some clinicians opt to have patients sign the notes stating that these discussions were held. Forcing a non-consenting patient to receive a transfusion unwillingly can be viewed as battery, and a Jehovah’s Witness who accepts a transfusion can be spiritually cut off from a community of family and friends.
Trauma: Situations of trauma are difficult, in that medical directive cards may not be immediately available. If there is any doubt in a clinician’s mind as to the wishes of the patient or as to what is legally appropriate, it is recommended that the clinician treat per the accepted standards of care until legal documentation is available.
Transfusion Medicine and Hemostasis. https://doi.org/10.1016/B978-0-12-813726-0.00056-8 Copyright © 2019 Elsevier Inc. All rights reserved.
357
358
Burak Bahar, MD and Jeanne E. Hendrickson, MD
Unacceptable
Red cells
Oxygen therapeutics* *Products in development
Personal decision
Whole blood
White cells
Interferons* Interleukins* *Recombinant products available
Platelets
Platelet substitutes* *Products in development
Plasma
Immune globulins Clotting factor concentrate* Prothrombin complex Cryoprecipitate† Albumin‡ *Recombinant VIIa, VIII, IX available †Prepared with 0.9% sodium chloride injection (USP) diluent ‡Recombinant albumin in clinical trials
FIGURE 56.1 Blood components and fractions. (Reproduced from Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116, with permission from Elsevier.)
Pregnant Women and Children: The treatment of pregnant women and children deserves special attention. Given that minor children are not considered capable of informed consent, it is recommended that the clinician seek legal intervention in cases where the fetus or child is placed at risk by parental refusal for transfusion. Laws governing the locality in which the patient is treated determine whether a treating physician can emergently transfuse a non-consenting pregnant woman or a child, with legal experts often determining that a life-saving blood transfusion is in the best interest of the child.
Blood Management: If a patient does not allow transfusion, the treating physician should attempt to find an alternative therapy within the boundaries of the patient’s religious beliefs. Such options include blood conservation, optimizing coagulation, and use of non-blood adjunctive therapies. If time allows, adequate preoperative planning and incorporation of strategies to maximize erythropoiesis may decrease the likelihood of severe anemia intraoperatively or postoperatively. Blood conservation can also be achieved by reducing blood loss through decreased phlebotomy and meticulous surgical care, intraoperative blood salvage, and/or acute normovolemic hemodilution. Depending on what products are deemed to be acceptable by the individual patient and what the clinical situation is, coagulation may be optimized with vitamin K, cryoprecipitate, 1-deamino-8-d-arginine vasopressin (DDAVP), fibrinogen concentrates, antifibrinolytic drugs, prothrombin complex concentrates, or recombinant factor VIIa. Potential adjunctive therapies to increase RBC mass and improve oxygenation include iron, folate, vitamin B12, erythropoietin, alternative oxygen carriers, or hyperbaric oxygen. The potential complications of each of these treatments must be weighed against their potential beneficial effects. The Hospital Information Services department of the Watch Tower Society has established more than 1700 Hospital Liaison Committees worldwide to support health-care providers in their care of Jehovah’s Witnesses. These committees can be reached at 718-560-4300 and https://www.jw.org/en/medical-library/ hospital-liaison-committee-hlc-contacts/united-states/.
Blood Refusal
359
TABLE 56.1 Jehovah’s Witness Religious Position on Medical Therapy Acceptable Treatment • Most surgical and anesthesiological blood conservation measures (e.g., hemostatic surgical instruments, controlled hypotension regional anesthesia, minimally invasive surgery, meticulous surgical hemostasis) • Most diagnostic and therapeutic procedures (e.g., phlebotomy for laboratory testing, angiographic embolization) • Pharmacologic agents that do not contain blood components or fractions such as the following: • Drugs to enhance hemostasis (e.g., tranexamic acid, epsilon-aminocaproic acid, aprotinin, desmopressin, recombinant factor VIIa, conjugated estrogens) • Hematopoietic growth factors and hematinics (e.g., albumin-free erythropoietin, iron) • Recombinant products (e.g., albumin-free coagulation factors) • Synthetic oxygen therapeutics (e.g., perfluorochemicals) • Non–blood volume expanders (e.g., saline, lactated Ringer’s, hydroxyethyl starches) Personal Decision (Acceptable to Some, Declined by Others) • Blood cell salvagea (intraoperative or postoperative autotransfusion) • Acute normovolemic hemodilutiona • Intraoperative autologous blood component sequestrationa (including intraoperative plateletpheresis, preparation of fibrin gel, platelet gel, platelet-rich plasma) • Cardiopulmonary bypassb • Apheresisb • Hemodialysisb • Plasma-derived fractions (e.g., immune globulins, vaccines, albumin, cryoprecipitatec) • Hemostatic products containing blood fractions (e.g., coagulation factor concentrates, prothrombin complex concentrate, fibrin glue/sealant, hemostatic bandages containing plasma fractions, thrombin sealants) • Products containing plasma-derived blood fractions such as human serum albumin (e.g., some formulations of erythropoietin, streptokinase, G-CSF, vaccines, recombinant clotting factors, nuclear imaging products) • Products containing a blood cell–derived fraction • Epidural blood patch • Blood cell scintigraphy (e.g., radionuclide tagging for localization of bleeding) • Peripheral blood stem cell transplantation (autologous or allogeneic) • Other transplants (organ, HSC [hematopoietic stem cell], bone) Unacceptable Treatment • Transfusion of allogeneic whole blood, red blood cells, white cells, platelets, or plasma • Preoperative autologous blood donation aPatients
might request that continuity is maintained with their vascular system. not primed with allogeneic blood. cCryoprecipitate suspended in 0.9% sodium chloride injection (USP) diluent. Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116, with permission from Elsevier. bCircuits
Summary: An adult patient with decision-making capacity may defer some or all treatment modalities for themselves, which may include refusing blood products. Optimal management of patients who refuse blood transfusion requires close communication with the patient and their support network, early preoperative planning, and a thorough assessment of possible alternatives to transfusions.
360
Burak Bahar, MD and Jeanne E. Hendrickson, MD
Further Reading Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18(2), 105–116. Booth, G. S., & Pilla, M. A. (2016). Preventing the preventable: How the blood bank laboratory information system fails to protect patients that refuse blood. Transfus Apher Sci, 55(2), 245. Jassar, A. S., Ford, P. A., Haber, H. L., Isidro, A., Swain, J. D., Bavaria, J. E., et al. (2012). Cardiac surgery in Jehovah’s Witness patients: Ten-year experience. Ann Thorac Surg, 93(1), 19–25. Lawson, T., & Ralph, C. (2015). Perioperative Jehovah’s Witnesses: A review. Br J Anaesth, 115(5), 676–687. Rogers, D. M., & Crookston, K. P. (2006). The approach to the patient who refuses blood transfusion. Transfusion, 46(9), 1471–1477. Scharman, C. D., Shatzel, J. J., Kim, E., & DeLoughery, T. G. (2017). Treatment of individuals who cannot receive blood products for religious or other reasons. Am J Hematol. https://doi.org/10.1002/ajh.24889. Epub 8/18/17. Spahn, D. R., & Goodnough, L. T. (2013). Alternatives to blood transfusion. Lancet, 381(9880), 1855–1865. Zeybek, B., Childress, A. M., Kilic, G. S., Phelps, J. Y., Pacheco, L. D., Carter, M. A., et al. (2016). Management of the Jehovah’s witness in obstetrics and gynecology: A comprehensive medical, ethical, and legal approach. Obstet Gynecol Surv, 71(8), 488–500.