“We found that hospitals are collecting data on patients’ religion, but it’s just not clear how they use it to improve services,” says Amy Wilson-Stronks, project director for health disparities with the Joint Commission and principal investigator of the study.
The current Joint Commission standards require hospitals to respect patients’ spiritual needs, beliefs, and values. Spiritual care issues first appeared in the 1969 accreditation manual and were adopted into standards in 1992, Wilson-Stronks says.
How Religion Has Pioneered Blood Conservation Techniques
It’s 2 a.m. and you’re admitting a 45-year-old with coffee-ground emesis that just turned into bright red blood. The patient grabs your arm, “I am a Jehovah’s Witness,” he says. Then he calmly and decidedly says “no” to your advice to perform a blood transfusion.
This patient’s belief about transfusion comes from a Bible verse (Acts 15:19-21: “ … abstain … from blood.”). In general, Jehovah’s Witnesses have a firm religious directive not to accept blood products. Some are open to receiving their own blood and fluids back (e.g., autotransfusion and perioperative cell-saver devices). Some also accept pooled protein products.
As hospitalists, we need to find out what is acceptable to our patients prior to transfusion and (in some cases) modify practices for such patients as Jehovah’s Witness. This need has spurred the medical community to find alternative therapies.
Many countries use pre-operative iron and erythropoietin (EPO), autotransfusion, and cell-saver surgeries. By minimizing iatrogenic blood loss and optimizing cardiac and respiratory support, most patients can tolerate anemia, even in acute illness. The situation may call for a team approach with the hospitalist, hematologist, surgeon, anesthesiologist, interventional radiologist, pharmacist, and nurse. Each clinical scenario requires an individualized clinical management plan that respects the wishes of any patient who refuses blood transfusion.
Physicians have had to be concerned with Jehovah’s Witnesses’ refusal of blood transfusion for decades. Surgeries with high potential for blood loss (e.g., coronary bypass and total joint replacement) have forced healthcare providers to rethink and strategize other methods.1 These include early surgery or embolization, cautery, fibrin glue products, positioning the patient perioperatively to allow permissive hypotension, and normothermia. Some even phlebotomize before surgery, keeping volume isovolemic with saline. The idea is the blood lost perioperatively will be at a lower hematocrit—this is the hemodilutional technique.2 Some Jehovah’s Witnesses accept blood back post-operatively.
Physiologically, an otherwise healthy patient can tolerate a hematocrit down to 15%. In a landmark article in the New England Journal of Medicine in 1999, Hébert, et al., compared the outcomes of restrictive transfusion (hemoglobin 7-9 g/dL) with liberal transfusion (hemoglobin 10-12 g/dL) in critically ill patients.3 The mortality rate during hospitalization was significantly lower in the restrictive strategy group (22.2% vs. 28.1%, p=0.05). Hemoglobin levels at 7 g/dL have not been linked to increased myocardial oxygen consumption, poor wound healing, nor localized tissue hypoxia. In most cases, this level of anemia does not justify transfusion, as long as circulating volume can be maintained. More liberal transfusion to higher levels may have a paradoxical effect on microcirculation, increasing viscosity and decreasing better outcomes.
In most cases, you will not be able to transfuse a Jehovah’s Witness patient. In these cases, we offer several viable alternative therapies.4
1. Decrease blood loss. First, consider decreasing the amount of blood loss. This can include reducing the frequency of blood draws because the usual reason for these checks is to detect the threshold for transfusion, using pediatric or small volume tubes for phlebotomy and avoiding other unnecessary blood draws.
2. Consider alternatives to anticoagulant prophylaxis for DVT prophylaxis, such as intermittent pneumatic compression devices, and avoid medications that may have the adverse effects of anemia and thrombocytopenia. These include aspirin, NSAIDs, platelet aggregate inhibitors, and some antibiotics. Example: Substitute a proton pump inhibitor for an H2 blocker. If there is a strong clinical indication, such as aspirin, in cerebrovascular accidents, discuss the risks and benefits with the patient.
3. Use non-blood volume expanders—even before the patient shows clinical signs of blood loss. Crystalloids are the first line for volume replacement, including normal saline and ringer’s lactate. Colloids and starch solution have not been proven effective and may even be detrimental. As part of the ABC management of any acutely ill patient, oxygenation is essential. This includes optimization of cardiac output by improving preload, afterload, and possibly inotropic therapy. Also consider interventions that minimize oxygen consumption, such as appropriate analgesia and sedation or muscle relaxant, in the mechanically vented patient.
4. Treat anemia: Regardless of the EPO level, critically ill patients respond to high-dose EPO therapy. The use of EPO 330 u/kg daily for five days and then on alternate days for at least two weeks reduces the need for blood transfusion.5 Iron therapy has proven useful in maximizing the response to EPO. Hemostatic drugs, such as aprotinin, may decrease blood loss and prevent the need for blood transfusion. Other pharmacological agents that may enhance hemostasis include tranxexamic acid, epsilon-amino caproic acid, desmopressin, conjugated estrogen, and prothrombin complex concentrate. Vitamin K may also be useful in patients with malabsorption, on antibiotics or anticoagulants, or patients with liver disease.
5. Reduce the risk of blood loss: Recombinant activated factor VIIa has been shown to reduce blood loss in nonhemophiliac patients who are acutely ill.6 Doses ranging from 60 mcg/kg to 212 mcg/kg have been successful in published reports.7 Factors VIIa, VIII, and IX are available as recombinant products.
Fresh frozen plasma is separated from blood and may be acceptable to the Jehovah’s Witness. These proteins are indicated in coagulopathic patients, those with liver disease, and those requiring warfarin reversal. Cryoprecipitate includes factors VIII, XIII, fibrinogen, von Willenbrand factor, and fibronectin. This may be useful in a low-fibrinogen coagulopathy. Some surgical patients may accept a cell-saver device perioperatively that salvages their blood and fluid from the surgical site, filters it, and returns it to the patient.
If a patient becomes hemodynamically unstable (even after adequate intravenous fluid resuscitation) you must consider surgical intervention. It may be as simple as applying fibrin glue topically, or more invasive, such as removing an organ or sewing off a femoral artery laceration from cardiac catheterization to control hemorrhage. Angiographic embolization is commonly used in these circumstances as it is expeditious and generally a less-invasive way to stop bleeding. Risks and benefits from the loss of an organ, such as a kidney, or loss of fertility, as with a hysterectomy to stop bleeding, must be outlined.
Studies have shown that restrictive transfusion strategy in acutely ill patients has decreased morbidity and mortality. There are other risks of transfusions, such as transfusion reactions, lung injury, allergic reactions, sepsis, circulatory overload, and transmitted infections.
Dr. Mierendorf is associate residency program director for Kaiser Permanente in Santa Clara, CA, and clinical associate professor of medicine at the Stanford University School of Medicine.
- Transfusion Alternatives Documentary Series. Watch Tower Bible and Tract Society of Pennsylvania, 2004.
- Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E. Preoperative acute normovolemic hemodilution: a meta-analysis. Transfusion. 2004;44:632-644.
- Hébert PC, Wells G, et al. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-417.
- Clinical Strategies for Managing Hemorrhage and Anemia without Blood Transfusion in Critically Ill Patients. Hospital Information Services for Jehovah’s Witnesses. Watch Tower Bible and Tract Society of Pennsylvania, 2004.
- Corwin HL, Gettinger A, Rodriguez RM, et al. Efficacy of recombinant human erythropoietin in the critically ill patient: A randomized, double-blind, placebo-controlled trial. Crit Care Med. 1999;27(11):2346-2350.
- Eikelboom JW, Bird R, Blythe D, et al. Recombinant activated factor VII for the treatment of life threatening haemorrhage. Blood Coagul Fibrinolysis. 2003;14(8):713-717.
- O’Connell NM, Perry DJ, Hodgson AJ, O’Shaughnessy DF, Laffan MA, Smith OP. Recombinant FVIIa in the management of uncontrolled hemorrhage. Transfusion. 2003;43(12):1711-1716.