Refuse Blood Transfusion Research Articles

Heart Failing Jehovah Witness Patient Successfully Treated by Minimally-Invasive Left Ventricular Assist Device Implantation without any Blood Transfusions.

Heart-Failing Jehovah's Witness Patient Successfully Treated by Minimally Invasive LVAD Implantation without Any Blood Transfusions What sounds like a headline of a newspaper is the title of a case report regarding cardiac surgery in a high-risk patient, namely, a patient undergoing left ventricular assist device (LVAD) implantation for heart failure treatment. The authors were courageous enough to implant a LVAD in a Jehovah witness, a Christian denomination whose members categorically refuse blood transfusions. They have to be congratulated upon this minimally invasive procedure. Nowadays, cardiac surgeons usually do not have a problem performing coronary artery bypass graft surgery (off- or on-pump, probably with a mini-extracorporeal circulation) without blood transfusion. The same is true for isolated aortic valve replacement. However, LVAD implantation is a different story: Even if the primary implantation is successful without blood transfusions, the risk with the currently most-used LVADs (Heartmate II, Heartware) is still high that transfusion may be required. Several reports show that gastrointestinal bleeding occurs in 30 to 40% of LVAD recipients and, moreover, the threat of thromboembolism calls for repeated alteration of anticoagulation and transfusion of red blood cells and clotting factors after LVAD implantation. Another major problem is device infection, which can usually only be treated by device replacement. Can this be done without transfusion? Moreover, at a young age of 48 years it is foreseeable that this patient will suffer severe device complications rendering heart transplantation as the only and final option. Will the authors do the transplantation as a reoperation with an LVAD without transfusion as well? Considering these questions, it may not be fair convincing Jehovah witnesses that LVAD implantation can be safely performed without the risks of blood loss and—subsequently—transfusion, and that LVADs assure a better quality of life in the long-term. Finally, in case of bleeding, again the old ethical dilemma for the treating surgeons arises: to give the patient a blood transfusion against his explicit will or to let the patient die.

Severe Acute Anemia After Liver Transplantation in an Elderly Jehovah's Witness Treated With High-dose Erythropoietin and Ferric Carboxymaltose: A Case Report

BackgroundThere is no standard treatment for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells. Case reportAfter an orthotopic liver transplantation, an elderly Jehovah's Witness who refused blood transfusion presented with severe acute anemia with hemorrhagic shock. The calculated red blood cell loss was near 70%. Associated with surgical treatment and supportive measures, the patient was treated with high-dose erythropoietin and ferric carboxymaltose. ResultsThe patient presented a rapid increase in hemoglobin concentration and reticulocyte count with resolution of hemorrhagic shock after the proposed pharmacologic treatment combined with local hemostatic measures. She was transferred to a low-risk unit 4 days after transplantation and was discharged from the hospital on day 10. The hemoglobin concentration was normal 35 days after the bleeding event. ConclusionThis case demonstrated that a protocol with high-dose erythropoietin and ferric carboxymaltose may be an option for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.

Prospective randomised evaluation of a collagen/thrombin and autologous platelet haemostatic agent during cementless total hip arthroplasty.

Total hip arthroplasty (THA) can be associated with substantial peri-operative blood loss which can negatively influence a patient's clinical outcome. Few haemostatic agents have been tested in THA. The aim of this study was to determine whether the use of a collagen/thrombin/ autologous platelet haemostatic agent would result in a significant decrease of blood transfusions for patients undergoing primary THA. THA patients meeting inclusion/exclusion criteria (n=109) were enrolled in this prospective, double-blind trial and randomised to a treatment arm (standard haemostatic methods plus haemostatic agent) or control arm (standard haemostatic methods only). The primary outcome was transfusion. Secondary outcome measures included peri-operative narcotic usage and post-operative haemoglobin levels, pain scores, function, and general health quality of life. Transfusions were required by 5/60 (8.3%) patients in the treatment group and 7/49 (14.3%) in the control group (p=0.33). The mean number of units transfused was not significantly different between the treatment group (2.2±1.3) and the control group (1.6±0.5) (p=0.36). Haemoglobin values on post-operative days 1, 2, and 3 were significantly higher in the treatment group (p=0.002, 0.04, and 0.02, respectively). Hip Disability and Osteoarthritis Outcome Score and Short Form-12 scores were not different between the two groups. In relatively healthy patients undergoing primary cementless THA there was no significant difference in number of transfusions or number of units transfused. It is unlikely that we will routinely use the investigated haemostatic agent to reduce blood loss in a healthy patient undergoing THA. The product may have some benefit in patients who refuse blood transfusions, have minimal ability to increase blood volume, are undergoing total joint revision, or have markedly low pre-operative haemoglobin levels, but this needs to be demonstrated.

Why do we treat the children of Jehovah's Witnesses differently from their adult parents?

While many citizens may view an adult Jehovah's Witness’ refusal of the blood transfusion that might otherwise save her life as irrational, the refusal alone does not lead the courts...

The Gynecological Surgery of Jehovah´s Witnesses

Objective: To present our experience with the surgical treatment of various diseases in patients belonging to the Church of Jehovah´s witnesses. Methods: The study included 34 patients belonging to the Church of Jehovah´s witnesses who rejected blood transfusion. The operations on these patients were performed for malignant and benign disorders that could not be treated by conservative therapeutic procedures. Results: The operation records were evaluated according to a set of criteria including the type of surgical procedure estimated amount of blood loss, postoperative complications and the outcome of surgical treatment. The lest amount blood loss was secured by the robotic surgery. Conclusion: Jehovah´s witnesses represent a risk group of patients because of their refusal of blood transfusion. Indication for the operation and its performance represent serious decision steps that are always associated with a certain degrese of risk. However when the principles of bloodless surgery are followed the therapeutic results are very good and in the properly indicated cases the scope of risk is acceptable.

Blood transfusion refusal by pregnant and puerperal Jehovah's witnesses

Blood transfusion refusal by pregnant and puerperal Jehovah's witnesses

Case Report: Discontented Life versus Peaceful Death

In today's healthcare system, health professionals deal with many challenging dilemmas and controversies that are difficult to resolve. Among several issues, the issue of refusal of blood transfusion by the patient in an emergency situation has been debated a lot in the literature. It is a crucial issue that puts health care professional in a state of confusion, and creates ethical and legal dilemma to deal with. The health professional engage in ethical inquiry to identify the best possible option, based on ethical grounds and discover morally-justifiable solution while prioritizing a patient's interest. The pioneers in ethical theories and principles provide us a framework to ethical decision making. The widely used ethical theories include Utilitarian, and Kantism.

Surgery in Jehovah's Witnesses - our experience.

IntroductionSurgeons face a special challenge in treating Jehovah's Witnesses who refuse blood transfusion.AimTo present our surgical experience with this group of patients operated on in our department.Material and methodsA retrospective study of 16 unselected Jehovah's Witnesses patients was conducted between October 2004 and February 2012. We analysed gender, age, haemogram before and after surgery, types of surgery, postoperative complications and the need for blood transfusion, and/or other drugs stimulating erythrogenesis.ResultsEighty-one percent of patients were women; the average age of all patients was 57.3 years. Mean haemoglobin level, preoperative, postoperative, and on the day of discharge from hospital, was 12.5 g/dl, 9.7 g/dl, and 9.29 g/dl, respectively. Over the same time period, mean red blood cell count was 4.53 mln/µl, 3.58 mln/µl, and 3.37 mln/µl, respectively. Two out of 16 patients agreed to have blood transfusion. Drugs used for erythropoiesis stimulation included rEPO, ferrum, and folic acid. No surgical death was noted.ConclusionsWe found that abdominal surgery was safe in our small group of Jehovah's Witness patients. However, all Jehovah's Witness patients should be fully informed about the type of procedure and possible consequences of blood transfusion refusal. Two of our patients agreed to blood transfusion in the face of risk of death.

Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery

Management of anemic patients refusing blood transfusion remains challenging. Concomitant coronary artery disease further complicates management. We sought to decrease the likelihood of cardiac events by employing hypothermia and neuromuscular blockade, in addition to limited phlebotomy, in a critically anemic Jehovah's Witness patient following emergent colectomy. The patient's hemoglobin concentrations were trended with serial blood gases. Neuromuscular blockade was instituted with cisatracurium, followed by hypothermia to a target of 32°C. The patient's lowest hemoglobin levels occurred on postoperative day 3 before beginning to rise. There were no postoperative cardiac events reported during the patient's course of stay. She recovered well with no evidence of anemia or cardiac events at 1-year follow-up. We conclude that targeted hypothermia with neuromuscular blockade, as an adjunct to accepted techniques, may be an alternative for critically anemic patients with coronary artery disease refusing blood transfusion.

Adults who refuse blood transfusion in emergency, urgent and elective circumstances.

Surgeons dealing with an adult refusing a blood transfusion find themselves in an unenviable position, torn between wishing to preserve the patient's life while also respecting his or her wishes. This article looks at the legal framework for such circumstances as set out in the Mental Capacity Act 2005.

Outcomes in Bloodless Medicine Patients With Acute Gastrointestinal Bleeding

Introduction: Red blood cell transfusion is often indicated in acute gastrointestinal bleeding (GIB), but some patients refuse blood transfusion for personal or religious reasons. Limited data exists regarding the clinical management and outcomes in this population. We describe the in-hospital mortality and endoscopic outcomes of patients with overt GIB. Methods: A single center retrospective cohort study was performed using the clinical database of the Bloodless Medicine Referral Center at a university-affiliated hospital. Inclusion criteria were age 18 years or older, inpatient admission between January 2007 and January 2014, an ICD-9 diagnosis code for GIB, and documented refusal of blood transfusion. Results: Ninety-two patients (63% female, 37% male) met inclusion criteria. Mean age was 68 years (range 20-97) with a median length of stay of 5 days (range 0-48 days). A source of bleeding was documented in 86% of patients (35% upper, 51% lower, and 14% undetermined). For medical therapy, 76% received intravenous iron, 75% received erythropoietin, and 30% received aminocaproic acid. In-hospital mortality was 8.6%. Fifty-two patients (56%) underwent endoscopy (45% EGD, 30% colonoscopy, and 25% both). In the endoscopy group, mean admission hemoglobin was 9.2 g/dL (range 4.5-14.7), mean nadir hemoglobin was 7.8 g/dL (range 3.5-14.3) and in-hospital mortality was 1.9%. A source of bleeding was identified on endoscopy in 61% of patients. Of the 40 patients who did not undergo endoscopy, mean admission hemoglobin was 8.9 g/dL (range 3.5-14.9), mean nadir hemoglobin was 7.3 g/dL (range 3-13.2), and in-hospital mortality was 17.5%. Conclusion: In carefully selected Bloodless Medicine patients, endoscopy is safe and effective in the evaluation and treatment of acute GIB.

The refusal of blood transfusion for religious reasons and criminal liability of physician

The refusal of blood transfusion for religious reasons and criminal liability of physician

Profound Anaemia in a Jehovah's Witness following Upper Gastrointestinal Haemorrhage: Intensive Care Management

Management of the profoundly anaemic patient who competently refuses blood transfusion will always prove challenging. This article provides a review of treatment strategies based around a recent case of a patient presenting after major gastrointestinal haemorrhage. The main part of management involves providing supportive intensive care, paying particular attention to oxygen delivery and consumption, and minimising further blood loss. Specific treatments, such as pharmacotherapy to promote erythropoiesis, are based largely on indirect evidence or expert opinion. Virtually all aspects of care involve carefully balancing a shifting profile of risks and benefits; a team approach and close communication with the family are essential. This patient's successful outcome has extended our understanding of this area, which is discussed.

Blood loss and transfusion rates associated with transcatheter aortic valve replacement: Recommendations for patients who refuse blood transfusion

Transcatheter aortic valve replacement (TAVR) is less invasive than surgical aortic valve replacement and may be preferred for patients who refuse blood transfusions. Our study sought to define transfusion rates in TAVR, identify predictors and develop recommendations for patients who refuse transfusions. A large cohort of consecutive patients undergoing TAVR was prospectively studied. Blood loss and transfusion rates were observed in patients undergoing transfemoral (TF-TAVR) and transapical TAVR (TA-TAVR). Predictors for transfusion were investigated in a multivariate model. Of 373 consecutive patients, 270 underwent TF-TAVR and 103 TA-TAVR. Transfusion rates were significantly lower in TF-TAVR than TA-TAVR (11.1 vs 41.7%; P < 0.001). In patients who did not receive transfusions, blood loss was significantly lower in TF-TAVR than TA-TAVR (23.6 ± 12.2 g/l vs 28.9 ± 13.7 g/l; P = 0.004), but did not differ in transfused patients (36.9 ± 12.9 g/l vs 33.4 ± 21.2 g/l; P = 0.428). Predictors for transfusions were low baseline hemoglobin, female sex, low body weight and decreased renal function. In seven Jehovah's Witness patients, who refused transfusions, no vascular complications occurred and clinical outcome was excellent. In patients, who refuse transfusions, TAVR may be performed with good clinical outcomes provided a high baseline hemoglobin level, careful management of the access site and strict measurements to reduce blood loss. TF-TAVR is associated with less blood loss and a lower rate of transfusions than TA-TAVR, and may be the preferred option for patients, who refuse transfusions.

English

INTRODUCTION Jehovah's Witnesses are considered unusual patients because of their refusal to receive blood transfusions. Some practitioners do not consider the increased risk of death associated with refusal of blood transfusions as a sufficient deterrent. This religious conviction raises problems in the field of ethics and legal and medical management of patients for major

Reducing Postburn Injury Anemia in a Jehovah’s Witness Patient

Anemia is a complication of severe burn injury. Burn patients who refuse blood transfusions, such as Jehovah's Witnesses, present difficult challenges, and treatment paradigms need to be altered to reduce blood loss and increase red cell restoration. In this report the authors present a case of a 36-year-old Jehovah's Witness who suffered a 35% TBSA burn injury. In addition to standard burn injury treatment, the authors attempted to reduce blood loss with a combination of intraoperative (tranexamic acid) and perioperative (erythropoietin, intravenous iron) strategies.

Bloodless Surgery by a Regional Intra-arterial Tourniquet During Primary and Revision THA

Primary total hip arthroplasty (THA) and revision THA are associated with blood loss that can be significant. The purpose of this retrospective study was to compare the efficacy of intra-arterial occlusive balloons in reducing blood loss during primary and revision THA. Twelve patients (Jehovah’s Witnesses) scheduled for a primary (n=6) or revision (n=6) THA who refused blood transfusions were compared with 48 control-matched patients (primary THA, n=24; revision THA, n=24). All Jehovah’s Witnesses received an intra-arterial balloon preoperatively, and all control patients underwent conventional surgery. Intraoperatively, balloons were periodically inflated to reduce blood loss and deflated to prevent limb ischemia. Endpoints for the study were estimated blood loss, perioperative hemoglobin, mean hospital stay, mean operative time, amount of intraoperative fluid or blood administered, and complications. None of the patients with an occlusive balloon received blood, whereas the primary THA group received an average of 0.6 units (P=.08) and the revision THA group received an average of 1.9 units (P=.02). Estimated blood loss was significantly decreased in the balloon group compared with the primary THA group (145 vs 402 mL, respectively; P<.01) and the revision THA group (333 vs 767 mL, respectively; P<.01). No complications were associated with the intra-arterial balloons. All patients showed a significant reduction in hemoglobin immediately postoperatively compared with preoperative values. No statistically significant differences existed in the amount of fluids given intraoperatively or the mean hospital stay among all groups. Temporary internal tourniquets used as an adjuvant to surgery significantly reduce intraoperative blood loss during primary and revision THA.

Waivers and Negligence: Defining the Patient-Physician Relationship by Refusal of Blood Transfusions

This paper discusses a recent health law issue originating from British Columbia, Canada. In Hobbs v. Robertson, the health law issue in question is whether a waiver that bars physician liability for negligence is valid. This is an important question because any answer will have a significant effect on both health law and the patient-physician relationship dynamic. At present, there is no judgment on this case and the British Columbia Court of Appeals has, for the second time, remitted that action back to trial court. This inquiry addresses aspects of tort and contract law in the patient-physician relationship. To address this health law issue, three critical questions are analyzed. The first question is if a waiver can be valid between a patient and physician. The second is whether a waiver is valid only between a patient and a hospital or also with the physician. The final question asks if negligence may be included in a waiver. After analysis, three potential solutions are suggested and discussed with one being chosen as the most suitable for implementing.

Blood Management Strategies in Primary and Revision Total Knee Arthroplasty for Jehovah's Witness Patients

Primary or revision total knee arthroplasties (TKAs) may be associated with a marked amount of intraoperative or postoperative blood loss that potentially may lead to the need for blood transfusions. However, Jehovah's Witnesses usually refuse blood transfusions because of their religious beliefs. This may create clinical or ethical challenges for the treating physicians. Therefore, following established blood management protocols specifically designed for these patients may be beneficial for the performance of safe and transfusion-free procedures with minimal complications. In this report, we provide an overview of various potential preoperative, intraoperative, and postoperative blood management measures that may be used for the care of Jehovah's Witnesses who undergo knee arthroplasty procedures. In addition, we review reported outcomes of primary and revision TKAs in these patients.

Ethical and legal aspects of refusal of blood transfusions by Jehovah's Witnesses, with particular reference to Italy.

Ethical and legal aspects of refusal of blood transfusions by Jehovah's Witnesses, with particular reference to Italy.