• Patients Who Refuse Blood Transfusions - FAQs


    Patients may refuse
    blood transfusions
    or other procedures involving
    blood
    for several reasons, however the most well known is a religious objection expressed by Christians called
    Jehovah's Witnesses.

    Witnesses are sometimes mischaracterized as persons who refuse all medical care, but this is not the case. They buy health insurance when possible and seek the best quality modern medical care for themselves and their children. However, practicing Witnesses (as distinguished from non-practicing or persons who claim to be Witnesses but are not) will not accept transfusions of whole blood or any of the “four primary components,” namely
    red blood cells
    (RBCs),
    platelets
    (PLTs),
    plasma, and
    white blood cells
    (WBCs).
    Some Witnesses have chosen to accept
    blood subfractions
    —such as
    immunoglobulins,
    albumin,
    factor concentrates, as well as
    recombinant
    products that contain small amounts of a blood fraction—because this choice is left up to individual conscience. The majority hold to the belief that blood removed from the body should not be returned, so
    preoperative autologous donation
    for later transfusion is not acceptable. However, treatments such as
    cardiopulmonary bypass
    or other treatments in which his own blood circulates back into the patient during an ongoing medical or surgical procedure, are acceptable to many Witnesses. The basis for the Witnesses' refusal to accept blood transfusion is found in Biblical commands such as

    ;

    ;

    ; and
    . Other patients who are non-Witnesses refuse blood transfusions for reasons such as fear of blood-borne disease, or prior negative experience with transfusion, such as hemolytic or
    anaphylactic
    reactions.
    To others, it may be culturally distasteful.


    It can be a difficult situation for all concerned whenever a patient refuses blood or blood derivatives. Critical to the best outcome in such a situation is to achieve and maintain a good rapport with the patient. The doctor must not debate with the patient over his or her health care choice, because doing so makes the physician an adversary of his own patient. The patient may defensively refuse any or all medications or treatments that might otherwise have been acceptable. The focus of the health care team should be acting as the patient's advocate, seeking and providing the best possible therapy acceptable to the patient, whether delineated by religious, moral, or personal comfort grounds.


    There are those who hold strongly to beliefs they value more than their own present lives. Jehovah's Witnesses take such a moral position when it comes to the matter of blood transfusions. For Witnesses, there is a wide range of acceptable treatments, and the reasons given for Witnesses' decisions regarding accepting or refusing a particular medical modality may vary from person to person, according to the dictates of individual conscience.


    With this in mind, we invite registered users of NoBlood Wiki.


    Are you a healthcare professional with a question regarding what and/or why patients make their various bloodless healthcare choices? Are you an individual that chooses nonblood medical treatment? If so, please feel free to participate in the development of this project. Please keep in mind the following guidelines:


    The purpose of this project is to catalog frequently asked questions regarding patients who refuse blood transfusions. This includes some of the common answers given to these questions. We invite all healthcare professionals as well as the public to view this project as a tool to better understand the reasons behind some of the decisions that are made by patients who choose nonblood medical care. Please restrict your comments and contributions to this end. This is not the place to express personal opinions regarding the merits or seeming lack thereof behind the questions and answers considered in this project.


    Blood Transfusion


    Why do some patients refuse blood transfusions?


    1. Risk of disease.

    2. It is now widely known both among medical personnel and the general public that blood transfusion carries with it substantial risks. However, this is not the reason a practicing Jehovah's Witness refuses to accept a blood transfusion. The primary reason is that in their view the Bible prohibits the taking of blood into the body to sustain life. Pertinent Scriptures include
      , which says “Abstain… from fornication and from what is strangled [unbled meat] and from blood.” This command was given by the apostles to all Christians, based upon several prior commands from God: the order given by God to Noah at Genesis 9:3,4; multiple similar commands appearing in the Mosaic Law eight centuries later, at

      ; and

      ; and repeated for emphasis at
      . These verses, of course, do not use modern medical terms to prohibit the use of blood. However, Jehovah's Witnesses feel these Scriptures clearly preclude them from taking into their bodies, by any route, allogeneic whole blood or its primary components (i.e., red blood cells, white cells, platelets, and plasma).


    Why do some patients refuse
    Autologus Predonation
    ?


    1. Witnesses consider other Biblical statements (eg,

      ;

      ) as ruling out preoperative collection and storage of autologous blood (presurgical autologous blood donation or preoperative autologous blood deposit PAD) for later transfusion.

    Blood Fractions


    1. Why do some patients refuse blood fractions?

    2. Why do some patients accept blood fractions?

      1. Some feel that fractions are no longer whole blood or even one of the primary components of blood, nor are they used for the same reasons as whole blood or primary components.

    3. Why do some patients accept some blood fractions and not others?

      1. It can be noted that plasma proteins (fractions) move from a pregnant woman’s blood to the separate blood system of her fetus. Thus a mother passes immunoglobulins to her child, providing valuable immunity. Separately, as a fetus’ red cells complete their normal life span, their oxygen-carrying portion is processed. Some of it becomes bilirubin, which crosses the placenta to the mother and is eliminated with her body wastes. Some may conclude that since blood fractions can pass to another person in this natural setting, they could accept a blood fraction derived from blood plasma or cells.*

    4. Why do some patients refuse blood transfusions but accept fractions derived from blood that was donated by others?

      1. Some cite Deuteronomy 14:21 as a basis for accepting fractions derived from blood that was mishandled by others. There in the Mosaic Law, an Israelite was commanded: “YOU must not eat any body [already] dead. To the alien resident who is inside your gates you may give it, and he must eat it; or there may be a selling of it to a foreigner, because you are a holy people to Jehovah your God..." Accepting blood fractions that were derived from individuals who, from God's view, improperly donated their blood may perhaps be the same as accepting payment or benefiting from the sale of an unbled animal to a foreigner.
        Also one did not have to to extremes in the Bible to remove every trace of blood if the animal was properly bled. Jehovah's Witnesses believe that blood represents the life of the person and it is up to the individual Witness to decide if they feel that a fraction derived from blood still represents the life of the person.

    Plasma
    -derived fractions

    Albumin

    Immune globulins

    Cryoprecipitate


    Note:

    Cryoprecipitate resuspended in 0.9 percent sodium chloride injection (USP) diluent may be acceptable to some Witnesses, whereas cryoprecitate resuspended in plasma likely would not be.


    1. Why do some patients accept other blood fractions but decline Cryoprecipite?


    Others


    vaccines, antivenins


    Products containing plasma derived blood fractions


    Such as human serum albumin (e.g., some formulations of
    EPO,
    streptokinase,
    G-CSF, vaccines, recombinant clotting factors, nuclear imaging products)


    1. Why do some patients decline some medical preparations containing higher concentrations of albumin?

      • The perception may exist that albumin in larger quantities is included in the medication to perform one or more of its normal function(s) in the body (as a nutrient, a carrier molecule, a volume expander, or a fluid balancing substance), rather than in very minute quanitities only to chemically stabilize the medication.


    Hemostatic products containing blood fractions


    Recombinant factor VIIa, coagulation factor concentrates, prothrombin complex concentrate, fibrin glue and/or sealant, hemostatic bandages containing plasma fractions, thrombin sealants


    Note:

    Recombinant activated factor VII currently contains trace amounts of IgG from the manufacturing process.


    Red cell-derived fractions

    Hemin,
    Hemoglobin


    1. Why do some patients accept other blood fractions but decline Hemoglobin?

      • It acts too much like whole blood, by transporting oxygen.

    2. Why do some patients refuse
      red blood cells
      (RBC) but accept the RBC fraction hemoglobin?

      • The red blood cells aren't whole any longer, as they would be in packed RBCs. Since they have been broken apart, they are the same as any other fraction.


    Products containing red cell derived blood fractions


    Products containing a red cell-derived fraction, whether from a human or an animal source (e.g., iron supplements, hematin, interferon alfa-N3 (leukoderived))

    Examples?:
    Polyheme, etc.


    1. Why do some patients accept blood fractions but decline HBOCs (hemoglobin-based oxygen carriers)?

      1. HBOCs carry risk of exposure to viruses

      2. HBOCs, when transfused, because of the high concentration of hemoglobin, looks and/or gives the appearance of receiving a transfusion of whole-blood or RBCs.

      3. HBOCs are "so similar to the function of the whole component and carry on such a life-sustaining role in the body".

    2. Why do some patients refuse red blood cells (RBC) but accept HBOCs?

      1. Although HBOCs function and behave similarly to RBCs in their oxygen carrying capacity, they do not eliminate carbon dioxide as do RBCs. Even though it is made from RBCs, the RBCs are broken apart, the hemoglobin is taken out, chemically changed so it isn’t even technically hemoglobin anymore, and then chemically linked into a chain of molecules that can carry oxygen to tissues like blood does. Blood delivers O

        2

        and disposes of CO

        2

        , whereas PolyHeme® does deliver O

        2

        but can’t take the CO

        2

        out of cells like blood does, so it isn’t really exactly like the primary component of RBCs, or blood itself. The part of the primary component (RBCs) used is only a fraction, and the remainder of the blood (whole red cells, plasma, white blood cells, and platelets) is not used. It is not really one of the four primary components any longer.

      2. HBOC is no longer considered a hemoglobin molecule because it has been stripped of its DNA.


    White cell-derived fractions

    Interferon


    Products containing white cell derived blood fractions


    Products containing a white cell-derived fraction, whether from a human or an animal source (e.g., interferon alfa-N3 (leukoderived))


    Medical Treatments

    Intraoperative blood salvage
    (Cell Salvage)(IOBS):


    Intraoperative or postoperative autotransfusion. A process that reduces blood loss. Blood is recovered during surgery from a wound or body cavity. It is washed or filtered and then, perhaps in a continuous process, returned to the patient.


    Note:

    Patients might request that continuity is maintained with their vascular system.


    1. Why do some patients decline the use of blood salvage (IOBS)?

      1. They do not understand how IOBS works

      2. They view any blood leaving the vascular circulatory system as spilled blood and as such should be disposed of.

      3. The blood involved in IOBS may not remain in a continuous circuit as in the case of the suction tube perhaps being removed from the surgical area.

    2. Why do some patients decline autologous predonation (AP) but accept blood salvage (IOBS)?

      1. Unlike IOBS, AP is not considered part of the current surgical procedure

      2. With AP, the blood has been stored

      3. WIth AP, oxygen carrying capacity is diminished

      4. With AP, the blood has been separated from the body

      5. With AP, personated blood is seldom actually used

    3. Why do some patients that refuse blood transfusions for religious reasons accept the use of blood salvage (IOBS)?

      1. IOBS may be considered an extension of circulatory system, especially if it is configured as a closed circuit. A nonblood priming solution would be a requirement.

      2. The use of IOBS is considered part of an ongoing surgical procedure, even if it may not be configured as a closed circuit system, as long as it is primed with a nonblood solution.

    4. Why do some patients that refuse blood transfusions for religious reasons accept the use of blood salvage even if it does not involve a continuous circuit?

      1. IOBS is considered part of the current surgical procedure

    5. Should blood that has left the vascular circulatory system be poured out or disposed of?

      1. The blood might be viewed as not having left the body entirely; it is considered still a part of the circulatory system perhaps as in the case of internal hemorrhaging, the body absorbs some of this pooled blood.


    Intraoperative autologous blood component sequestration


    Including intraoperative platetetpheresis, preparation of fibrin gel, PLT gel, PLT rich plasma)

    Note:

    Patients might request that continuity is maintained with their vascular system.


    Apheresis


    Note:

    Circuits not primed with allogeneic blood.


    Hemodialysis (Dialysis)


    A process that functions as an organ. In hemodialysis, blood circulates through a machine that filters and cleans it before returning it to the patient.


    Note:

    Circuits not primed with allogeneic blood.


    1. Why do some patients decline the use of a Dialysis Machine?

    2. Why do some patients that refuse blood transfusions for religious reasons accept the use of a Dialysis Machine?

    Epidural Blood Patch


    A process that stops spinal fluid leakage. A small amount of the patient's own blood is injected into the membrane surrounding the spinal cord. It is used to seal a puncture site is leaking spinal fluid.


    1. Why do some patients decline the use of a Epidural Blood Patch?

      • They feel that since their blood has left the body, it should be discarded.

    2. Why do some patients that refuse blood transfusions for religious reasons accept the use of a Epidural Blood Patch?

      • They feel that their extracted blood is used topically as opposed to re-entering their circulatory system.

      • They feel that this would be acceptable if performed during the course of the current surgical procedure.

      • They feel that from the time it is extracted from the vein into a syringe to the time it is re-infusion into the spinal column, the blood actually is never exposed to air.

      • They feel that since it is just a momentary interruption and the blood is not being stored for later infusion.

      • They feel that IF it can be configured as a closed circuit (see
        Epidural Blood Patch
        for example), it would be acceptable.


    Note:

    See
    Epidural Blood Patch
    for discussion regarding available alternatives.

    Cardiopulmonary Bypass
    (Heart-Lung Machine)


    Heart-lung machine. A process that maintains circulation. Blood is diverted to an artificial heart-lung machine where it is oxygenated and directed back into the patient.


    Note:

    Circuits not primed with allogeneic blood.


    1. Why do some patients decline the use of a Heart-Lung Machine?

    2. Why do some patients that refuse blood transfusions for religious reasons accept the use of a Heart-Lung Machine?

    Acute Normovolemic Hemodilution
    (ANh)


    A process that reduces blood loss. During surgery where
    blood
    is diverted to bags and replaced with a nonblood volume expander. The blood remaining in the patient during surgery is diluted, containing fewer
    red blood cells. During or at the end of surgery, the diverted blood is returned to the patient.


    Note:

    Patients might request that continuity is maintained with their vascular system.


    1. Why do some patients decline the use of hemodilution?

    2. Why do some patients that refuse blood transfusions for religious reasons accept the use of hemodilution?

    Blood cell scintigraphy
    (Labeling or Tagging)


    A diagnostic procedure. Involves radionuclide "tagging" for localization of bleeding.
    Some blood is withdrawn, mixed with medicine, and returned to the patient. The length of time one's own blood is outside the body may vary.


    1. Why do some patients decline Labeling or Tagging of their blood?

      • They feel that since their blood has left the body, it should be discarded.

      • They feel that receiving any quantity of whole blood is objectionable.

    2. Why do some patients that refuse blood transfusions for religious reasons accept Labeling or Tagging of their blood?

      • Some feel that transfusion of such small quantities of blood would never be considered life-sustaining in itself, therefore Leviticus 7:11 does not apply because the soul is not in it.

      • Some feel that properly bled meat contains comparable quantities of residual blood, the eating of which is rarely met with hesitation.

    Plasmapheresis


    Treats illness.
    Blood
    is withdrawn and filtered to remove
    plasma. A plasma substitute is added, and the blood is returned to the patient. Some physicians may want to use plasma from another person to replace that from the patient's blood.


    1. Why do some patients decline Plasmapheresis?

    2. Why do some patients that refuse blood transfusions for religious reasons accept Plasmapheresis?

    Platelet Gel


    Autologous - made from your own blood. Seals wounds, reduces bleeding. Some blood is withdrawn and concentrated into a solution rich in platelets and white cells. This solution is applied on surgical sites or wounds. In some formulations, a clotting factor taken from cow's blood is used.


    1. Why do some patients decline the use of platelet gel?

    2. Why do some patients that refuse blood transfusions for religious reasons accept the use of platelet gel?

    Peripheral blood progenitor cell transplantation
    (Stem cell treatments)


    Autologous or allogeneic.


    1. Why do some patients decline Peripheral blood progenitor cell transplantation?

      • They feel that blood progenitor cells will naturally become blood cells and so decisions regarding the progenitors should be the same as if they had already become whole blood. Sometimes this reasoning is compared to pregnancy where the fetus will naturally become a baby and so decisions regarding that fetus should be the same as if it were already born.

      • They are misunderstanding the term "stem cell," and are mistakenly voicing their objection to the use of embryonic stem cells.

    2. Why do some patients that refuse blood transfusions for religious reasons accept Peripheral blood progenitor cell transplantation?

      • They feel that the blood progenitor cells are not blood.

    Organ Transplant


    An organ transplant is the transplantation of a whole or partial organ from one body to another (or from a donor site on the patient's own body), for the purpose of replacing the recipient's damaged or failing organ with a working one from the donor site. Organ donors can be living, or deceased.


    See also


    References


    Related Articles

    Pediatric Court Orders
    |
    Erythropoietin (EPO)
    |
    Acute Normovolemic Hemodilution (ANH)
    |
    Prepare Now For a Possible Medical Emergency
    |
    Epidural Blood Patch (EBP)
    |
    Intraoperative blood salvage
    |
    Blood Fractions Guide

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