Jehovah's Winesses and Transfusions

[jhaig]

I'm curious about whether or not there is any case in which a physician can override a patient's religious beliefs in order to save the patient's life with a transfusion of blood products. If the patient has signed a form refusing treatment with blood products based on religious beliefs, is that the final word on the issue? What legal repercussions would follow if a Witness was transfused against their will (ie: emergency where patient cannot express their beliefs, cannot sign form, etc.)? Our policy is not to transfuse in these cases, but I'm always thinking 'what if'.

[AMcCord]

There are a number of cases where minor age children have been transfused contrary to their parents wishes. The physican(s) and/or hospitals have gone to court to get a judge's order to do so. The parents seem to lose most of the appeals they file to stop the transfusions (and not just for cases involving religious issues). If an adult is capable of giving informed consent and refuses, that's that. I know of a case where a patient died after refusing transfusions for a GI bleed. The patient was asked to sign a release very carefully drawn up specifically for her case. Her family saw the issue from her point of view, so no issues there with the potential of a law suit.

I haven't seen anything about disputes where blood is transfused in a trauma situation, but it would be interesting to hear someone else's experiences.

[Eagle Eye]

At our place we see trauma patient who are Jehovah's witness but gets blood in emergency. As long as if the physician can prove that transfusion was necessary to save patient's life, I do not see a problem. We had a patient who received multiple transfusion and later on when patient refused to get more blood but by then patient's condition was Ok and there was no need for transfusion.

ANother case where patient received transfusion while in trauma(patient non responsive) and later on patient refused to get more transfusion once patient was OK refused transfusion. Patient went back to OR where he needed the transfusion and according to patient's advance directive which was signed during hopital stay we were able to give blood and patient survived.

[rcurrie]

Something I learned in law school: If you give an adult patient blood knowing that it is against their wishes, you can be charged with criminal battery, even if they are unconscious and you deem it necessary to save their life, and you can certainly be "sued for everything you've got", as the saying goes. This does not apply to minors. However, it is prudent to get a court order if you are going to go above parental wishes and give blood. It puts the onus on the court rather than you. I have never seen the court rule in favor of a patient in this regard.

The gray area involves the case where you know your patient is a Jehovah's Witness, but do not know their specific wishes. It is gray because the refusal of blood is personal to each Jehovah's Witness. One may say yeah, give me all you've got. Another will say only autologous blood. Another will limit it to derivatives such as albumin and specific clotting factors. Another only allows blood salvage with immediate reinfusion after washing. We have perhaps the largest per capita population of Jehovah's Witnesses in the world in my service area. They have an annual convention here that draws close to 225,000 people for a week. I have seen the full gamut of patients. We work with them to meet their wishes. Legally, that is your only alternative to prevent serious lawsuits.

BC

[AngiB]

Do you have any procedures where autologous blood is collected in the OR without using a cell saver? I have an anesthesiologist who found an article on the internet about Hemodilution and has concocted a plan to basically do his own thing. He made one critical error... he called me and asked for a donor bag or the "stuff" you put in the bag so it won't clot. Just curious if anyone has a process they use or if he truly was making it up as he went.

Angie

[rcurrie]

Angi,

We don't have a procedure, but hemodilution has been around for a long time. Some people think it is great, but others have decided that it puts the patient at higher risk. The theory is, you remove a unit or two of blood in the surgical suite and replace it with a crystalloid volume expander, and when they bleed X amount, their oxygen carrying capacity is lowered at a slower rate than if they lost undiluted whole blood. When the patient approaches hemodynamic instability, you infuse their own blood that was withdrawn earlier. There are practice guidelines for hemodilution. Hopefully your gasman is following such. We do not assist with the hemodilution program here- the perfusionists do that duty. More power to them! This is an area I avoid like Denge Hemorrhagic Fever (it's coming to a city near you).

BC

[jhaig]

Should our form be modified to include a checklist of sorts describing the products available for infusion and then have the patient check off what they will take? Could this be a generic form or should each case be handled individually? I guess I wasn't aware of the fact that some Witnesses will accept certain products while others will not.

[Lcsmrz]

I worked midnights at a facility that had alot of of JW patients, and occasionally I issued units at 0100 to sneak in a transfusion at the patient's request while the family and friends were away. I also noted that some JW surgery patients accepted the Cell Saver, since the blood "never touched air or was disconnected from body".

Just as any other religious denomination, JW's have various beliefs and strength of conviction. You have to admire the ones who give up their life for their faith, when medical science has a solution to their needs.

[AMcCord]

We have patients who ask what color the product is - if it's yellow, they will accept it and if it's red (blood), they won't. On the consent, they add what products specificially the patient will accept - the only one I have personally seen, the patient handwrote that on himself with signature and date. This is also very explicitly charted by the nurse. Many will accept RhoGAM after they have asked us to explain how the product is manufactured. We also have a file of official material provided by their church to educate ourselves about their doctrine.

We have seen a few JW patients whose physician's wrote orders for blood products without discussing that whole 'blood thing' with them. The first anybody knows about this is when a consent is presented and the patient declines to sign it. We have already started work and have a record started for them, so we note on their record that they are JW. A couple of these folks have come back in through our ER to ICU with blood orders and we notified the physican, documenting this notification, as to what the patient's previously stated wishes were. (We did not refuse to carry out the doc's order, we did not delay in getting product ready for transfusion and we would never refuse to provide any product the patient agrees to accept.) The patients were grateful for our concern for their values.

[jhaig]

Wonder how a bloody platelet unit fits into the color scheme...

Sounds like a case-by-case basis with a specially crafted consent for each patient may be the way to go. Thanks for the info.

[rcurrie]

Sounds like a case-by-case basis with a specially crafted consent for each patient may be the way to go. Thanks for the info.