Major abdominal surgery in Jehovah’s Witnesses

Abstract

Introduction Patients who are Jehovah's Witnesses pose difficult ethical and moral dilemmas for surgeons because of their refusal to receive blood and blood products. This article outlines the personal experiences of six Jehovah's Witnesses who underwent major abdominal surgery at a single institution and also summarises the literature on the perioperative care of these patients. Methods The patients recorded their thoughts and the dilemmas they faced during their surgical journey. We also reviewed the recent literature on the ethical principles involved in treating such patients and strategies recommended to make surgery safer. Results All patients were supported in their decision making by the clinical team and the Hospital Liaison Committee for Jehovah's Witnesses. The patients recognised the ethical and moral difficulties experienced by clinicians in this setting. However, they described taking strength from their belief in Jehovah. A multitude of techniques are available to minimise the risk associated with major surgery in Jehovah's Witness patients, many of which have been adopted to minimise unnecessary use of blood products in general. Nevertheless, the risks of catastrophic haemorrhage and consequent mortality remain an unresolved issue for the treating team. Conclusions Respect for a patient's autonomy in this setting is the overriding ethical principle, with detailed discussion forming an important part of the preparation of a Jehovah's Witness for major abdominal surgery. Clinicians must be diligent in the documentation of the patient's wishes to ensure all members of the team can abide by these.

Management of High-Risk Obstetrical Patients with Morbidly Adherent Placenta in the Age of Resuscitative Endovascular Balloon Occlusion of the Aorta

“…This discussion with patients should be performed privately and confidentially. It must be free of coercion and judgment from outside parties [14,15]. In circumstances of a religious basis for blood refusal, patients frequently consult with religious leaders, family and friends prior to making a decision, but the final decision must rest in the hands of the patient herself.…”

“…Many patients who do not accept blood will accept other methods to improve hemoglobin levels. Iron, vitamin B12, folate and recombinant erythropoietin can be used preoperatively [14,15]. Intravenous iron is preferred over oral preparations because of faster and more reliable increases in hemoglobin.…”

“…There is variability in the products that Jehovah's Witnesses will and will not accept [15]. Generally, whole blood products are prohibited, but some patients will accept fractions, such as hemoglobin, albumin, cryoprecipitate, clotting factors and platelets.…”

“…A study of Jehovah's Witness patients found that, although most would decline conventional blood products, 76% would accept other blood components [20]. Most will accept crystalloid, colloid, recombinant factor VIIa (rFVIIa), factor VIII (FVIII), fibrinogen, tranexamic acid (TXA), and artificial blood substitutes [14,15], but use of individual blood components alone may have limitations. Cryoprecipitate, containing FVIII, factor XIII (FXIII), von Willebrand factor (vWF) and fibrinogen, can be used in a postpartum hemorrhage to reduce risk of coagulopathy due to hypofibrinogenemia.…”

The Jehovah’s Witness obstetric patient – a literature review

“…The patient's refusal of treatment stemming from their religious beliefs presents much more of a challenge. In such circumstances "the good of the patient" is often differently understood by those involved, where physicians tend to perceive it as a choice of the most effective and safe procedures, whilst patients prefer to stay within the boundaries of religious rules [4,5,[7][8][9][10].…”