Witness Patients Research Articles

Outcomes of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy for peritoneal malignancy in Jehovah’s witnesses: Single centre 20 year experience

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex intervention, particularly in patients with advanced pseudomyxoma of the peritoneum. Intra and post-operative bleeding are common and blood and blood products may be required to replace blood volume and control bleeding. Jehovah's Witness Patients with peritoneal malignancy, who for religious reasons, refuse blood or products, pose particular problems in complex interventions.

Outcomes of perioperative management in Jehovah's Witness patients undergoing surgeries with a risk of bleeding: a retrospective, single-center, observational study

Outcomes of perioperative management in Jehovah's Witness patients undergoing surgeries with a risk of bleeding: a retrospective, single-center, observational study

Legal and psycological risks of the changes in creed about blood-transfusion: A case of Jehova's witness patient

Legal and psycological risks of the changes in creed about blood-transfusion: A case of Jehova's witness patient

Biomedical Ethics for Jehovah’s Witnesses and Patient Blood Management

Jehovah’s Witnesses refuse blood transfusions according to religious beliefs, and for this reason, most hospitals and doctors have refused their treatment. There are more than 100,000 religious people in Korea, but there are few bloodless centers that can receive their treatment. So, the number of Jehovah’s Witnesses patients visiting bloodless centers in Soonchunhyang University Bucheon Hospital has been increasing every year. Despite this situation, no legal or medical countermeasure has yet been proposed against them. Therefore, I would like to take a bioethical approach based on “principles of biomedical ethics” and introduce “patient blood management” which is currently spreading in advanced medical countries.

Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. the Perioperative Management of Adrenalectomy in a Jehovah's Witness Patient: a Case Report.

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Preoperative Hemoglobin Optimization in Jehovah's Witness Cardiovascular Surgery Patients with Anemia and Barriers to Care

Cardiac surgery has a risk for extensive blood loss which poses a particular challenge in individuals refusing blood transfusions. Additionally, preoperative anemia with a hemoglobin (Hb) below 13 g/dL in men and 12 g/dL in women is associated with increased short and long-term complications and mortality and increases the need for blood transfusion support. The current guidelines for perioperative anemia management recommend optimizing hemoglobin levels prior to surgery and utilizing blood conservation techniques during the procedure. At present red blood cell (RBC) transfusions during cardiac surgery are usually recommended when Hb levels are below 7-8 g/dL a restrictive transfusion strategy to reduce complications. However, the use of any RBC transfusions is associated with worse outcomes in cardiac surgery compared with those who do not receive transfusions.We have found that JW seek out quality health care and accept the vast majority of medical treatments once they are educated. The Transfusion Free Medicine Coordinator's role in the Anemia Clinic is to endorse clinical strategies for managing hemorrhage and anemia without blood transfusion. They educate and counsel the patients so they can decide as to what blood fractions and cell salvage techniques they will accept. We have found that some Health Care Providers are unaware that ESAs also contain albumin so JW patients may be given this product without that knowledge. The vast majority of patients will accept the use of ESAs but find the cost prohibitive.Jehovah's Witness patients have provided a natural case study for examining how well adjuvant therapies can improve preoperative anemia without transfusions and continue with good outcomes. Hb optimization is achieved through the use of intravenous iron and, if needed, erythropoiesis stimulating agents (ESAs). In Table 1 we highlight our single center data in which all cardiovascular surgeries were performed by a surgeon experienced in blood-conservation strategies. Our thirty-day re-admission rates for all patients was zero percent, compared to state-specific data, which estimates about an 11.7% rate of re-admission. The data illustrate the need to have a target Hb 13 or above to allow for the decline that may occur during the hospital stay. Of note no thromboembolic events have occurred with the use of an ESA in this group.Although ESAs are approved to optimize Hb in orthopedic surgery, they are not covered for cardiac surgery which has presented a significant challenge to patients who can not safely proceed to surgery until a target Hb between 13 to 15 g/dL is achieved.These data highlight the utility and safety associated with the use of ESAs for patients who do not accept blood products at an experienced Center for Transfusion-Free Medicine, such as ours. At this time, since insurance companies do not cover the cost of ESAs for patients needing life-saving cardiovascular operations, cost is a prohibitive barrier for patients. Unfortunately, it is not uncommon for patients to have to borrow money from others or set up payment plans. We hope that analyses like ours will help drive changes in reimbursement policies, particularly for patients who based on religious convictions, cannot receive blood products, and thus for whom pre-operative hemoglobin optimization is of utmost importance. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:Erythropoiesis-stimulating agent (ESA) are indicated for the treatment of anemia due to Chronic Kidney Disease in patients on dialysis and not on dialysis, Zidovudine in patients with HIV-infection, anemia due to myelosuppressive chemotherapy and reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery

Safety and feasibility of urological procedures in Jehovah's Witness patients.

To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Over my dead body: Self-determination, proxy consent, and proportionate reason in the treatment of a Jehovah's Witness patient with severe traumatic hemorrhagic shock

When a Jehovah’s Witness patient is traumatically injured, the lack of uniform professional consensus guidelines and the cultural knowledge deficit of many clinicians adds an additional layer of legal and ethical complexity to the inherent difficulty of managing a critically ill patient. We present here the case of an incapacitated Jehovah's Witness patient with severe traumatic hemorrhagic shock. We go on to discuss the historical and contemporary case law on proxy refusal of blood transfusion for the incapacitated adult, as well as the ethics of self-determination and the application of the principle of proportionate reason in the management of the critically injured Jehovah's Witness patient.

AML-104: Westchester Medical Center (WMC) Approach to Jehovah’s Witness Acute Myeloid Leukemia (AML) Patients

<h3>Objective:</h3> Development of a bloodless therapeutic approach to management of AML in Jehovah's Witness patients <h3>Design:</h3> Our center developed an approach for bloodless management of AML in adult patients in line with the religious beliefs of Jehovah's Witness patients. <h3>Setting:</h3> There are over 8 million Jehovah's Witnesses worldwide. Their world headquarters is located 30 miles from WMC, and the area supports a sizable population of Jehovah's Witnesses. <h3>Eligible Patients:</h3> Eligibility criteria include: >18 years of age, confirmed diagnosis of AML, and refusal to accept transfusion of blood products. <h3>Interventions:</h3> The protocol emphasizes the optimization of hemoglobin and platelet count, practicing conservative measures, such as minimizing blood draws and invasive procedures and using prophylactic measures against potential complications such as gastrointestinal bleeding. Our protocol includes: pediatric tubes, limited blood draws, IV iron, erythropoietin, weekly romiplostim, vitamin B12, folate, and aminocaproic acid. Venetoclax was planned for patients, given its less hematopoietic burden than traditional intensive chemotherapy. <h3>Main Outcomes Measures:</h3> The primary outcome is overall survival. Secondary outcome is progression free survival. Outcome measures include hemoglobin and platelet counts. <h3>Results:</h3> We present our first patient using this approach to evaluate efficacy and safety of this bloodless induction protocol, a 57-year-old gentleman with newly diagnosed AML. We initiated venetoclax and decitabine, along with all supportive interventions outlined above. Unfortunately, the patient felt unwell after the initial doses of chemotherapy and declined further treatment and left against medical advice. The patient's total hospital stay was six days. We saw no qualitative, logistical, or administrative concerns with the bloodless approach. On discharge, the patient's hemoglobin was 3.8 g/dL and his platelet count was 4 k/mm³. He eventually was admitted to another hospital, where he expired without AML treatment. We were unable to measure our primary and secondary outcomes, given our patient did not complete treatment. <h3>Conclusions:</h3> Though our initial patient did not complete his induction chemotherapy, from a qualitative analysis, our supportive care measures to optimize hemoglobin and platelet counts and limit bleeding risk were delivered without issues and may serve as a model for other centers with patients declining blood products in their leukemia care.

Vena Cava Tumor Thrombus Associated With Renal Angiomyolipoma in a Jehovah's Witness Patient

We present a case of a young premenopausal female patient who was found to have a left-sided renal mass consistent with angiomyolipoma (AML) with Mayo Level IIIa vena caval tumor thrombus. The patient is of Jehovah's witness faith and would not accept blood transfusion. The following case report discusses workup and treatment for AML with tumor thrombus extension, as well as pre-operative optimization and intra-operative techniques during nephrectomy and thrombectomy to minimize blood loss in a patient unaccepting of blood transfusion.

Use of a Hemoglobin Substitute (HBOC-201) to Treat Acute Anemia in a Leukemic Patient with Anti-Vel Antibodies

BackgroundThe Vel-negative blood type is a rare autosomal recessive trait, occurring in 1 in 4000 persons. It is extremely difficult to supply blood to patients with anti-Vel antibodies, and the situation is even more challenging for Vel-negative patients with leukemia who may have high transfusion needs. There are case reports of treatment with hemoglobin substitutes in Jehovah's Witnesses and surgical patients. To the best of our knowledge, we report the first use of a hemoglobin substitute, HBOC-1201 (HemoPure) to treat a patient with refractory acute myeloid leukemia (AML) and anti-Vel antibodies.Case ReportOur patient is a 67-year-old Caucasian man with a one-year history of acute myeloid leukemia, refractory to multiple hypomethylator- and chemotherapy-based regimens. History is also significant for coronary artery disease with type 2 NSTEMI due to severe anemia. He has experienced prolonged pancytopenia due to leukemia and chemotherapy and required blood transfusions approximately weekly. Anti-Vel antibodies make transfusion of compatible blood challenging, and we utilized a hemoglobin transfusion threshold of 5 g/dL. Working with the American Red Cross and the American Rare Donor Program (ARDP), we transfused 44 units of Vel-negative blood over a one-year period, depleting the available Vel-negative units in North America. He presented to the hospital with productive cough and dyspnea. Initial labs revealed acute on chronic anemia with hemoglobin 3.5 g/dL. CT of the chest revealed right lower lobe pneumonia. Given critical anemia in the setting of pneumonia and possible sepsis, the patient needed immediate blood transfusion. Compatible Vel-negative blood was not available in North America. While awaiting availability of international blood units through the Red Cross and ARDP, we considered the choices of 1) transfusing incompatible blood or 2) administering a blood substitute. Because individuals with anti-Vel antibodies may develop severe acute hemolytic transfusion reactions when transfused incompatible blood, we chose to treat with HBOC-1201 (Biopure Corporation, Cambridge, MA), a bovine hemoglobin polymer that lacks a red blood cell membrane and thus red cell antigens such as Vel. We obtained an emergency IND from the FDA and local IRB approval. Three 32-gram units of HBOC-1201 were successfully transfused, with hemoglobin rise from 3.5 to 4.5 g/dL. Common adverse effects associated with the use of acellular hemoglobin substitutes include increase in concentration of methemoglobin and vasopressor effects leading to elevated blood pressure, fluid overload, and myocardial infarction. Our patient was monitored closely and tolerated the transfusion without any apparent adverse events.ConclusionDuring a challenging clinical situation, we successfully treated severe acute anemia in a patient with refractory AML and anti-Vel antibodies, using the acellular bovine hemoglobin-based blood substitute HBOC-1201, when compatible blood was not available. The infusion was tolerated without complications. Hemoglobin substitutes may be considered as bridging treatments in critically anemic patients such as those with hematologic malignancies when red blood cell transfusion is not an option. DisclosuresNo relevant conflicts of interest to declare.

Bloodless surgery and gynecological patients among Jehovahs Witnesses.

The aim of this research is to present our experiences with the surgical treatment of gynecological patients among Jehovahs Witnesses. Moreover, the medical, moral, and ethical problems in this regard have been highlighted. 75Jehovahs Witnesses patients were operated on for various benign and malignant gynecological diseases between 2007and 2018. All of these patients were operated on according to the rules of blood-sparing surgery. The operations were assessed according to the dia-gnosis, mode of surgery, estimated blood loss, and disease outcome. Excessive blood loss did not occur during any of these operations, and the estimated blood loss for the same procedure was 10to 550 mL. Jehovahs Witnesses gynecological patients is agroup of high-risk patients because they refuse to undergo blood transfusion. Nevertheless, the principles of blood-sparing surgery should be applied to not only Jehovahs Witnesses patients but also to all patients in general. Even if ablood transfusion is the last resort to solve issues pertaining to excessive blood loss during complicated operations, the said procedure always carries certain risks. Therefore, blood transfusion should be performed only on rare occasions. Jehovahs Witnesses patients categorically refuse blood transfusion even if it is the only way to save ones life. Even though the legislation of the Czech Republic deals with this problem, there are other moral and ethical aspects that need to be addressed in this regard.

Perioperative blood conservation strategies for pediatric scoliosis surgery.

Many pediatric patients with severe scoliosis requiring surgery have baseline anemia. Pediatric scoliosis fusion surgery is associated with perioperative blood loss requiring transfusion. As such, many patients in this surgical population could benefit from a perioperative blood conservation program. Here we present a narrative review of perioperative blood conservation strategies for pediatric scoliosis surgery involving nurses, transfusion medicine physicians, anesthesiologists, surgeons, dieticians, perfusionists and neurophysiologists spanning the pre-, intra- and postoperative phases of care. The review highlights how perioperative blood conservation strategies, have the potential to minimize exposures to exogenous blood products. Further, we describe a relevant example of blood conservation related to the care of a Jehovah's Witness patient undergoing staged scoliosis repair. Lastly, we outline areas which would benefit from clinical studies to further elucidate perioperative blood conservation interventions and their outcomes relevant to pediatric scoliosis surgery patients. Interdisciplinary communication and meticulous blood conservation strategies are proving to be a means of reducing if not eliminating the need for allogeneic blood products for surgical correction of pediatric scoliosis.

Heart transplant in Jehovah's Witness patients: A case-control study

Heart transplantation (HTx) improves quality of life and survival in patients with advanced heart failure. Jehovah's Witnesses (JW) patients decline blood transfusion (including red cells, plasma and platelets) and are prohibited from heart transplantation at many centers. We report our experience with 20 consecutive JW patients with advanced heart failure who declined blood products referred to our center for HTx consideration. Of these, 7 were declined for transplant due to prior sternotomy, need for multi-organ transplant, or being too well. Of 13 JW patients accepted for heart transplant listing, 8 underwent HTx at our center. Compared to non-JW controls without prior cardiac surgery matched for age and listing status, JW HTx recipients had comparable incidence of primary graft dysfunction, rejection, allograft vasculopathy, and survival and hemoglobin up to 1 year. With appropriate selection, patients who are JW and decline blood products may successfully undergo heart transplantation.

Nontranfusional Management of Severe Anemia in an Adolescent Jehovah's Witness Patient

Severe anemia in Jehovah's Witness patients has long been a complex and sometimes divisive issue, especially in children and adolescents. In adolescent patients old enough to express their wishes, the decision to transfuse becomes more complicated. We present the case of a 12-year-old Jehovah's Witness female with severe anemia (hemoglobin of 2.6 g/dL) secondary to menorrhagia. She was successfully managed without transfusion, for which the patient and her family were deeply grateful. This case demonstrates that it is possible to manage severe iron deficiency anemia without transfusion.

Blood transfusion and alternatives in Jehovah's Witness patients.

More than 8.5 million people in the world observe the Jehovah's Witness faith, and require unique consideration for perioperative blood management as they generally refuse transfusion of blood and blood products. This review addresses a collaborative approach to each patient throughout the perioperative arena. The principles of this approach include optimization of hemoglobin levels preoperatively, attention to blood-salvaging methods intraoperatively, and minimization of blood draws postoperatively. In addition, we review the technologies currently in development as transfusion alternatives, including hemoglobin-based oxygen carriers. Progress has been made recently in the field of synthetic blood alternatives and hemoglobin-based oxygen carriers, which may lead to improved outcomes in this patient population. Utilization of multiple prevention and mitigation strategies to optimize oxygen supply and decrease oxygen demand will lead to decreased incidence of critical anemia and subsequent improved mortality in Jehovah's Witness patients.

Our experience of lung resection in patients who decline blood transfusion for religious reasons

ObjectiveSurgical treatment for patients who refuse blood transfusion due to religious beliefs is an important issue related to medical safety. Few reports have examined pulmonary surgery for these patients, and we analyzed clinical characteristics in such cases.MethodsTen Jehovah’s Witness (JW) patients with lung tumor resection who declined blood transfusion for religious reasons between December 2013 and February 2020 at the Fukushima Medical University Hospital were included. Median total intraoperative blood loss was 17.5 mL (range 5–150 mL). Fibrin glue was used intraoperatively for 8 patients. Final pathological examination revealed pulmonary adenocarcinoma in 9 cases and metastasis of bladder cancer in 1 case. In 8 patients with pulmonary adenocarcinoma examined for epidermal growth factor receptor (EGFR) gene mutation, 6 cases showed mutation. No patients had serious complications, but 1 patient displayed temporary anemia due to postoperative hemorrhagic gastrointestinal ulcer.Result and conclusionsOur findings confirm that pulmonary resection is feasible and safe for JW patients if performed by experienced medical staff. However, awareness of complications associated with perioperative bleeding is important. Each JW patient should be interviewed individually and every available perioperative option aimed at blood-sparing management, including use of blood coagulation factors and fibrinogen concentrates, should be carefully discussed and clarified. In this study, the EGFR gene mutation rate was higher than usual for cases of lung adenocarcinoma. Further studies are necessary to assess clinical features in JW patients with lung cancer.

Hybrid Double Valve Replacement for Multivalvular Disease With Severe Mitral Annular Calcification.

Severe mitral annular calcification poses a significant challenge, particularly in higher risk, frail, elderly patients with multivalvular disease. Both surgical and transcatheter options exist but remain fraught with risks of paravalvular leak, atrioventricular groove disruption, patient prosthesis mismatch, and left ventricular outflow tract obstruction. We present an innovative hybrid surgical approach to manage severe aortic and mitral valve disease in a Jehovah's Witness patient with severe circumferential mitral annular calcification.

Role of arthroplasty in the Jehovah's Witness population.

Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely. We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications. A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%. To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.

The right of Jehovah's witnesses to refuse and to accept blood transfusion

nema