A Jehovah's Witness patient's refusal of blood transfusions presents a unique set of constraints on the medical management of a bleeding patient. These constraints prompt the health care provider to consider alternative bloodless treatment modalities. The present case and others
5-10 demonstrate that patients do survive with very low hemoglobin levels because of the body's ability to compensate for anemia. In our case, a major surgical procedure was the definitive treatment, which required in-depth risk-benefit discussions between the patient and multiple specialists.
Our institutional policy and procedure manual had no resources or directives specific to Jehovah's Witness patients. The patient was an alert, competent adult who chose not to receive a blood transfusion for religious reasons. The Accreditation Council for Graduate Medical Education general surgery program requirements state, “Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.”
11 Furthermore, residents are expected to demonstrate “respect for patient privacy and autonomy” and “sensitivity and responsiveness to a diverse patient population, including ... religion.”
11
The surgical team in our case conducted an online search to locate and review evidence from scientific studies and culturally relevant resources related to Jehovah's Witness patients with severe anemia. A patient representative contacted the Jehovah's Witness Hospital Liaison Committee, which sent 2 regional physician members to participate in medical treatment discussions at the patient's bedside. This supportive environment allowed the patient and his family to decide which options were acceptable to them and clarified for the medical team which options were prohibited by the Jehovah's Witness faith. The health care team ensured that the patient's religious beliefs would be honored during all aspects of his care.
The United States legal system has consistently ruled that competent adults have the right to informed consent and may accept or refuse treatment. This precedent began with the case of Mary E. Schloendorff vs The Society of New York Hospital in 1914, in which the judge stated, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”
12 The Patient Self-Determination Act of 1990 requires institutional health care providers to ask patients if they have an advanced directive, to record patient preferences for end-of-life care in the medical record, and to develop institutional policies regarding the right to have patient decisions respected by health care personnel when a patient is not able to advocate for themselves.
13 To the authors' knowledge, there are no officially recognized Jehovah's Witness no-blood advance directive forms, and this patient did not have any type of written advance directive. If no advance directives exist, a discussion should be held and documented with the patient and his or her surrogate medical decision maker, if applicable, to discuss worst case scenario care options before a medical emergency occurs. If a signed advance directive does exist, health care providers should attempt to ascertain if the information in the advance directive accurately reflects the patient's current beliefs and wishes for care and to document that discussion.
Health care providers should be aware of how patients' religious beliefs may impact treatment options. Surgery, the definitive therapy needed for the patient in the present case, was not initially offered as an option by the health care providers because of the high risk for adverse effects. Surgeons typically treat anemic patients with blood transfusions, and when this standard of care is not an option, they are often unsure of how to proceed. This mindset can hinder the selection of an alternative treatment option and result in an inadequate informed consent process. The surgical team waited until day 3 before acknowledging that nonsurgical treatment was not stabilizing the patient's condition. If surgery had been offered immediately as an option, the patient could have undergone the operation on day 2 with a higher hemoglobin level and with less risk.
Numerous reports in the literature discuss blood conservation and bloodless treatment alternatives.
14-18 The approaches commonly involve addressing the source of anemia, minimizing blood draws, maximizing oxygen delivery, and reducing oxygen demand.
14-18 Medications that aid hematopoiesis, such as erythropoietin, folate, and vitamin B
12, may be initiated. If the patient is coagulopathic, then FFP, coagulation factor VIIa, and amino-caproic acid can be used in addition to oral or intravenous vitamin K.
14-18 Although not available at the time of the present case, the US Food and Drug Administration has recently approved the use of prothrombin complex concentrates such as Kcentra and Beriplex for reversal of oral anticoagulants with vitamin K—dependent coagulation factors.
18 However, these products, as well as anti-inhibitor coagulant complexes, contain human plasma and would need to be discussed with any Jehovah's Witness patient before initiation of treatment. With the advent of newer pharmacologic agents and medical devices, the lines have blurred for what constitutes as acceptable blood treatment options for Jehovah's Witness patients. Autotransfusion and blood subproducts such as FFP, cryoprecipitate, clotting factors, and albumin are considered by the Watch Tower Bible and Tract Society of Pennsylvania, the governing body of the Jehovah's Witnesses, to be the personal choice of each individual to receive or refuse.
19 Individuals decide for themselves whether or not these products are in accordance with their religious beliefs.
14-18 A dual approach with health care providers and a Jehovah's Witness Hospital Liaison Committee member can provide the patient with both the scientific and religious information needed to make an informed treatment decision.
Our patient's neurologically intact survival is extremely rare. Carson et al
1 found a 100% mortality rate in patients with a postoperative hemoglobin level of 1 to 2 g/dL and a 54% mortality rate in patients with postoperative hemoglobin level of 2 to 3 g/dL.
1 Our patient's hemoglobin level was 2.7 g/dL preoperatively and 1.8 g/dL postoperatively, which, to our knowledge, is the lowest documented hemoglobin level in a patient who survived without a blood transfusion.
8 The lowest hemoglobin level documented in a patient who survived with a blood transfusion was 0.7 g/dL, which was observed in a patient with a rare blood type who experienced bleeding from an injured axillary artery and who was treated with intravenous fluids until blood arrived.
5
The patient's ability to survive a major surgical procedure with such a low hemoglobin level poses the question: how was he able to do it? The delivery of oxygen is determined by the oxygen content of the blood and cardiac output, as well as the ability of the tissue to extract oxygen. The body compensates for anemia by increasing cardiac output (increased heart rate, contractility, decreased blood viscosity, and decreased peripheral vascular resistance, as well as a rightward shift in the oxygen-hemoglobin dissociation curve and increased oxygen extraction). Oxygen delivery is redundant in a resting patient in that it exceeds extraction by a factor of 4. Inadequate oxygen delivery may not be apparent until a hemoglobin level of 5 g/dL is achieved in resting, otherwise healthy patients.
20
Our patient had compensatory tachycardia, and although we did not measure his cardiac output and systemic vascular resistance, we presume contractility was probably markedly increased. His systemic vascular resistance was most likely decreased because of sepsis in addition to his compensation for his anemia. Whether or not there were other compensation mechanisms involved in our patient's survival (ie, chronic renal failure, infusion of intravenous immune globulin, anesthesia techniques, or more efficient oxygen offloading) would require further investigation.
A review of the literature includes much discussion regarding restrictive vs liberal transfusion practices.
1,3,4,21 Our case clearly would have warranted blood transfusion (barring his refusal) because of the documented risks associated with a hemoglobin level less than 6 g/dL coupled with physiologic changes, rapid bleeding, and an emergent surgery. Of note, the length of the procedure and amount of blood loss were quite low for this type of major operation, emphasizing the importance of damage control philosophy in surgery and good technique. Whatever the mechanism, the outcome in our patient and in patients of the other case reports
5-10 of severe anemia speaks to the amazing homeostatic mechanism of the body.
The tenets of osteopathic medicine include a commitment to the dynamic interaction of mind, body, and spirit and the body's ability to heal itself.
22 As osteopathic physicians, we pledge to provide compassionate quality care, to partner with our patients to promote health, and to display integrity and professionalism.
23 Our patient and his family truly trusted our team to provide the best care possible, and they had no doubts that we would honor their religious beliefs and stay within the mutually agreed upon plan of care no matter the outcome. The authors believe this strong physician-patient relationship and our patient's unwavering religious faith were key to his survival, even though they cannot be scientifically proven or replicated.