If the pt is unconscious, how would it be known that he is a JW? If he's carrying an advanced directive that ID's him as a Witness and outlines his wishes regarding blood, then the healthcare team should follow the directive.

If there is no documentation, do you honestly think the family would say, "Well, he's a JW, but we want you to transfuse him anyway"? I just can't envision that sort of scenario, although stranger things have happened.

Didn't we already discuss this very same scenario in a previous thread which was ultimately closed? I'm not trying to be rude, but it almost feels like you're trying to stir the pot.

So you've been in several situations in which an unconscious pt's relatives said, "He's a Jehovah's Witness, but we want you to give him blood anyway"? OK.

In the absence of a directive and family/POA, then obviously the healthcare team will have to proceed with what they think is the best treatment. One thing in medicine is certain: Never assume.

I guess I just have a hard time imagining that the family of an unconcious JW who has no directive on his person would say, "Well, John is a JW and wouldn't want blood, but we want you to transfuse him anyway." If anything, you would think the family would keep mum about the pt's religious beliefs to ensure that their wishes were carried out.

Once again we hear the subjective phrases “in the patient’s best interest” and “the treatment most likely to save life,” with reference to blood transfusion therapy. Many clinicians are still “wedded” to blood transfusion and believe that it is the only intervention that can save certain patients’ lives. However a growing body of opinion in the medical world is challenging that view. One reason for this is that blood that has been stored for any length of time loses much of its ability to offload oxygen to the tissues. In fact this ability can be impeded by as much as 80%. (Shander, et al. Hemodilution and Transfusion Avoidance. Transfusion Alternatives in Transfusion Medicine 2001;3:27–31

Donat Spahn, Professor of Anesthesiology at the University Hospital, Zurich, Switzerland, stated: “Efficacy of red blood cell transfusions has never been formally evaluated the way drugs and biologics are tested today prior to governmental approval… Large studies have failed to demonstrate an outcome benefit in liberally transfused patients. In contrast, there is strong evidence that liberal transfusion of red blood cells adversely affects morbidity and mortality in surgical and critically ill patients.” — Benefits of Red Cell Transfusion: Where Is The Evidence? Transfusion Alternatives in Transfusion Medicine 1999;1:6–10

Yes, blood transfusions apparently do save lives. But what is it about the blood that is lifesaving? Not its ability to deliver oxygen to the tissues in an emergency, but rather its acting as a volume expander. In this it may be no more effctive than a non-cellular fluid such as physiologic saline. On the other hand, the transfusion of red blood cells may in fact do more harm than good.

Professor James Isbister, world-renowned haematologist at Royal North Shore Hospital in Sydney and Clinical Professor of Medicine at the University of Sydney, Australia, stated back in 1991:

“A blood transfusion was previously seen as the gift of life, but the tables have been turned and the general perception now is that bloodless surgery and the avoidance of transfusion may be the gift of life.” — Why Haven't We Learnt Our Lesson: Autologous Blood Transfusion. The Medical Journal of Australia, 1991;155:139–140

Many doctors remain poorly informed about both the lack of evidence that blood does what it is intended to do, and the availability and efficacy of alternative modalities. They will no doubt continue to transfuse to make themselves feel better. Their more progressive colleagues, however, are calling for transfusion medicine to become evidence based with better use made of the alternatives to donor blood. And the evidence is mounting that the clinicians who are prepared use the alternative strategies may be the ones who are working "in the patient's best interests."

As Shander, et al, point out in the above quoted article in TATM, “Red blood cell (RBC) transfusions are normally performed to increase the oxygen carrying capacity of circulating blood. Through this increase, tissue oxygen delivery should rise, thus improving tissue oxygenation and cell function. In reality, however, banked blood has little oxygen delivering ability… Another reason for transfusing allogeneic blood is to alleviate symptoms secondary to acute or subacute anemia. Many such symptoms may result from inadequate circulating volume, not the anemia itself. Restoring the patient to a euvolemic state frequently eliminates these symptoms.”

So, despite a persistent belief on the part of many that “only blood will do,” there is an alternative intervention to correct much of the morbidity of anemia, and that essentially comes down to volume replacement. Then, with high-inspired oxygen support, the patient’s depleted red blood cells will, in many cases, continue to do their job.

Yes, there is a risk that the patient may still not have sufficient reserves of hemoglobin to maintain organ function, but this risk must be weighed against the risk of giving patients an untested biologic (blood) that has killed countless patients over the six decades it has been used “in the patient’s best interests.” And when the patient has indicated that they do not want to be treated with allogeneic blood, then, instead of standing around and arguing with relatives of the patient as to who is making the “best” decision, the patient’s choice should be respected and non-blood management proceeded with before the patient’s condition deteriorates further.

Yes, no one is denying that in certain circumstances blood transfusions have saved lives. The administration of red blood cells in a fluid medium may have bought the surgeons a little more time to control hemorrhage. As you say, though, it is nearly always the transfusion of fresh, whole blood that has this capacity. This is why Shander and his associates, who have implemented "a policy of universal transfusion avoidance as part of our bloodless medicine and surgery program," advocate ANH or cell salvage, where it is the patient's own fresh, whole blood that is enlisted. No doubt they do still give banked blood to those patients not in the program, and no doubt can point to numerous successes where the patient survived. Less clear is how many patients would have lived without the transfusions and how many have died despite, or because of, blood transfusions.

Bruce Spiess M.D., Professor and Vice-Chairman of Anesthesiology, Chief of Cardiothoracic Anesthesia, Director of Research, Department of Anesthesiology, Virginia Commonwealth University admitted: "There are few if any articles that support transfusion actually improving patient outcome." He adds that many transfusions "may do more harm than good in virtually every instance except trauma", increasing "the risk of pneumonia, infections, heart attacks and strokes." — Risks of transfusion: outcome focus. Transfusion, 2004; Volume 44 (December) Page 4S.

In view of the uncertain benefits and known risks of transfusion, surely a patient who has indicated that he or she does not want a transfusion should have those wishes respected and not overridden by either medical staff or relatives who do not share their view?

There is a lengthy discussion of this subject in the book Transfusion-Free Medicine and Surgery, (2005) edited by Nicolas Jabbour, in its first chapter entitled Legal and Administrative Issues Related to Transfusion-Free Medicine and Surgery. Section headings include Emergency/incometent adults (patients known to be Jehovah's Witnesses), Emergency/incompetent adults (no information available), and Disagreeing family members. The chapter discusses a number of court cases in the United States that ruled in favour of the doctor who, in doubt administered blood. However, it goes on to state:

"This enforces the necessity of clear policies and procedures within a transfusion-free program to clearly delineate such possibilities in advance. This is mostly true when electively treating adult patients undergoing high-risk procedures. The refusal of blood in such situations should equate with any other consent between physician and patient prior to initiating therapy. Refusal of blood transfusions should not be different from any other directive given by the patient. The consent form developed in a transfusion-free program should clearly stipulate that the patient's wishes should not be questioned, even if the patient becomes incapacitated and even if their life is endangered due to lack of transfusion (see Figures 1.1 and 1.2).
"In the case of an emergency, health care providers should do their best to ascertain whether or not the patient has previously expressed his or her position either verbally or in writing. Exercising such due diligence can greatly reduce, if not eliminate, liability and possible legal action...

"What if questions arise about the patient's Jehovah's Witness status?
Most Jehovah's Witness patients carry a wallet-sized advance medical directive/release card that documents their refusal of blood. However, due to negligence or perhaps unforeseen circumstances, some Jehovah's Witness patients may not always have this document with them. In cases where the patient was previously a patient at the hospital, chart notes can be checked [7,9]. There may also be a family member or friend previously appointed by the patient as health care agent or surrogate decision-maker. In regard to adults who are viewed as incompetent, if they never had decision-making capacity, the law views them as the same as minor children lacking capacity. However, the law is different for those who have had such capacity but are currently incapacitated.
If prior to losing capacity the adult was rational and capable of expressing his or her views and opinions regarding unacceptable treatment, a doctor or hospital is obligated to honor the patient's decision even if the patient is incapable of speaking for himself or herself."

The section on Disagreeing family members concludes:

"In summary, the patient's decision should control their medical treatment. The fundamental rights of personal privacy, bodily self-determination (informed consent) and, for Witness patients, religious freedom, would be rendered void if respect for a patients health care decisions were contingent upon the unanimous agreement of the patient's spouse or relatives. Health care providers should not be unduly concerned about litigation whenever these rights are upheld."

I can only repeat that it is imperative for hospitals to put clear guidelines in place for such contingencies.

Julie,

I wanted to pause to thank your for your input on the ethical issues involving non-blood management of cases. The questions you raise are not new to those of us in the field. We struggle with the issue of helping our physicians provide optimal care for all while at the same time acknowledging the patients right to choose. Though very rare there are times when decisions must be made using the best information available and there are times when a patients lack of preparedness causes them harm.

I am older now but once I was an athlete. I had many coaches and was directed by many coaching styles. I learned that each season it was my job to adapt to the coach. It wasn't my job to analyze coach's motives. I will say that the coaches that "harped" on areas where I lacked ability were not usually my favorites - at the time. Looking back from years later however they are the ones I remember most fondly. Interesting isn't it? Your persistence in the forums should and does refine us. If my tone is at times hard realize that it comes from passion for excellence and reflects my personal frustration as I navigate the life and death waters of patient care as an imperfect man. I am in a business where perfection is the goal and demand. I am in a profession where imperfect people are given the task of delivering perfect care. If I have taken some of your comments as taunts it is simply me facing my own lack of perfect answers.

Sincerely

__________________
Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email

Julie, To answer your question ......what would you do if pt came in unconscious and next of kin said pt is one of Jehovah's Witnesses but there is nothing in writing? I would ask next of kin, has your mother (brother, sister etc.) ever told you what they would want done if they needed blood? My experience in the last 13 years has been responses like this "she said she didn't want blood." I would then go on to ask, did your mother ever say what she would want if she were going to die without blood? Again I got responses like "She said she still wouldn't want blood". I would then go on to say, "We are going to honor your mother's wishes and not give her blood but I assure you we will treat her aggressively with every nonblood therapy that is appropriate."
I would tell the physicians to not give blood and document very carefully the conversation I had with the next of kin.
On the other hand if patient came in unconscious and there was no information that the patient is one of Jehovah's Witnesses either in writing or by next of kin, the next of kin's decisions would prevail.
I teach the ED staff if a patient comes in and verbally says "I don't want blood!!" and suddenly loses consciousness, they are to not give blood and call me to sort it out. Our Risk Management Department supports this method.

Julie, I can only speak for myself. If we are told the patient is a Jehovah's Witness we know the religion mandates no blood transfusions so we proceed in that direction even if the next of kin says otherwise. I'm not saying we would blatantly go against the next of kin but I would begin to investigate the situation with the primary goal of getting the best care for the patient while respecting their religious beliefs.
You have continued to insert "the best treatment to promote health and life in the doctor's opinion." In formal Bloodless/Blood Conservation Programs doctors very willingly request help in determining what the best treatment may be for that particular patient. As the Coordinator of the program I am a patient advocate first and foremost. Doctors participate in our program because they also respect the patients' right to make decisions concerning their own health and body.

Julie, As I mentioned in my reply to you, I can only speak for myself. There's no point in arguing over a situation that could have many answers. If you do not agree with how I practice my profession, that's OK, you have every right to feel that way.