It’s challenging to provide care to patients who decline blood transfusions. We’ll review the reasons for declining blood prod- ucts and the nurse’s role in providing appropriate, ethical care. We’re not advocating for or opposing any religion – just provid- ing information to support nursing practice. Background Jehovah’s Witnesses do not accept blood transfusions because they believe the Creator forbids it through the Bible. Particularly, “You shall not partake of the blood of any flesh, for the life of all flesh is in its blood. Anyone who partakes of it shall be cut off,” (Leviticus 17:13,14); “Be sure you do not eat the blood because the blood is the life…[and] because you will be doing what is right in the eyes of the Lord,” (Deuteronomy 12:23- 25); “You are to abstain from food sacrificed to idols, from blood…you will do well to avoid these things,” (Acts 15:22-29). 1-3 This belief extends to whole blood, stored autologous blood, red cells, white cells, plasma and platelets. 4-6 Are There Exceptions? In 2000, a clarification was published. 7 Citing Deuteronomy 12:26: “The blood of your sacrifices must be poured beside the altar of the Lord your God,” it emphasizes the instruction to “pour the blood out.” This opens the door to approaches in which the blood is maintained in contact with the vascular system and never “poured out” of the body. Many, therefore, will accept hemodiluted cardiopulmonary bypass and continuous auto- transfusion postoperatively in which a closed-loop system is used. 3,5 However, the guidance states, “A Christian must decide for himself how his own blood will be handled in the course of a surgical procedure, medical test, or current therapy. Ahead of time, he should obtain from the doctor or technician the facts about what might be done with his blood during the pro- cedure. Then he must decide according to what his con- science permits.” 7 Believers make personal choices regarding fractionated components such as albumin, cryoprecipitate, immunoglobulin, interferon and replacement factors such as for hemophilia. 5 Advance Planning is Key A multidisciplinary approach must include nurses, physicians, perfusionists, and patient support personnel as well as the ethics committee and the committee that deals with bloodless surgery or blood use evaluation. 2 Policies should include hospital documents relating to blood refusal, including release forms and consent; any special identi- fication system such as a colored wrist band or other alert; and special policies relating to issues with minors. 4 Hospitals may wish to consult with local congregations during planning to facil- itate communication. Systems for clinical, emotional, and spiritu- al support for patients, families, and clinicians are important, par- ticularly when patients are critically ill or when death occurs. 2 Elective surgery patients have a number of options. Agents to support red cell production such as erythropoietin, iron, and B- complex vitamins are important, particularly if anemia exists. 5,6,8,9 Folic acid supplementation and an iron-rich diet can also be useful both pre- and postoperatively. 6,8,9 Education about options such as continuous postoperative autotransfusion is important; patients may not be aware of this approach and can then make their own informed decisions. Caring for Patients Jehovah’s Witnesses are instructed to carry a pocket card expressing their wishes in an emergency in case they are unable to make their wishes known personally. 3 If one of Jehovah’s Witnesses chooses to receive blood or a blood prod- uct, privacy and confidentiality is essential. They are encour- aged to report indiscretions of others, 4 so it is essential to dis- cuss the matter with the patient privately, just as you would with any sensitive matter. Visitors and pastoral calls may need to be limited according to patient wishes. 2,4 Hospital crisis intervention and support teams should be activated as soon as possible in emergency situations. A patient may wish to discuss options with trained elders who form the congregation’s Hospital Liaison Committee and are on call for this purpose. In addition to advising patients, they can access the Hospital Information Services Network, a repository of information, including research literature that can be faxed to clinicians. 3 It is essential that the patient initiates this contact to maintain privacy and confidentiality. 2,4 Postoperatively, blood conservation is essential. Minimize blood volume loss from phlebotomy by first ensuring that each test is necessary and by using pediatric collection tubes or point- of-care testing where possible. 9 Continue with iron and folic acid supplements and erythropoietin and implement continuous autotransfusion if the patient allows it. What About the Research? In 1977, the Texas Heart Institute reported on a series of 542 patients who had cardiovascular operations without transfusions after the first open heart case in 1964. 10 Most deaths were com- plicated cases that presented great risk regardless of transfu- sion status. Anemia was a significant contributing factor in 12 deaths, and three deaths were directly attributed to blood loss. In July of 2012, a study from the Cleveland Clinic reports a com- parison between 322 Witnesses who had cardiac surgery with- Autotransfusion for Jehovah’s Witness Patients Clinical Update is edited by Patricia Carroll, MS, RN-BC, CEN, RRT, and supported by an educational grant from Atrium Medical Corporation. Summer 2012 Continued on page 2
Transcript
It’s challenging to provide care to patients who decline bloodtransfusions. We’ll review the reasons for declining blood prod-ucts and the nurse’s role in providing appropriate, ethical care.We’re not advocating for or opposing any religion – just provid-ing information to support nursing practice.
BackgroundJehovah’s Witnesses do not accept blood transfusions
because they believe the Creator forbids it through the Bible.Particularly, “You shall not partake of the blood of any flesh, forthe life of all flesh is in its blood. Anyone who partakes of it shallbe cut off,” (Leviticus 17:13,14); “Be sure you do not eat theblood because the blood is the life…[and] because you will bedoing what is right in the eyes of the Lord,” (Deuteronomy 12:23-25); “You are to abstain from food sacrificed to idols, fromblood…you will do well to avoid these things,” (Acts 15:22-29).1-3This belief extends to whole blood, stored autologous blood, redcells, white cells, plasma and platelets.4-6
Are There Exceptions? In 2000, a clarification was published.7 Citing Deuteronomy
12:26: “The blood of your sacrifices must be poured beside thealtar of the Lord your God,” it emphasizes the instruction to “pourthe blood out.” This opens the door to approaches in which theblood is maintained in contact with the vascular system andnever “poured out” of the body. Many, therefore, will accepthemodiluted cardiopulmonary bypass and continuous auto-transfusion postoperatively in which a closed-loop system isused.3,5 However, the guidance states,
“A Christian must decide for himself how his own bloodwill be handled in the course of a surgical procedure,medical test, or current therapy. Ahead of time, heshould obtain from the doctor or technician the factsabout what might be done with his blood during the pro-cedure. Then he must decide according to what his con-science permits.”7
Believers make personal choices regarding fractionatedcomponents such as albumin, cryoprecipitate, immunoglobulin,interferon and replacement factors such as for hemophilia.5
Advance Planning is KeyA multidisciplinary approach must include nurses, physicians,
perfusionists, and patient support personnel as well as theethics committee and the committee that deals with bloodlesssurgery or blood use evaluation.2
Policies should include hospital documents relating to bloodrefusal, including release forms and consent; any special identi-fication system such as a colored wrist band or other alert; and
special policies relating to issues with minors.4 Hospitals maywish to consult with local congregations during planning to facil-itate communication. Systems for clinical, emotional, and spiritu-al support for patients, families, and clinicians are important, par-ticularly when patients are critically ill or when death occurs.2
Elective surgery patients have a number of options. Agents tosupport red cell production such as erythropoietin, iron, and B-complex vitamins are important, particularly if anemiaexists.5,6,8,9 Folic acid supplementation and an iron-rich diet canalso be useful both pre- and postoperatively.6,8,9 Educationabout options such as continuous postoperative autotransfusionis important; patients may not be aware of this approach andcan then make their own informed decisions.
Caring for PatientsJehovah’s Witnesses are instructed to carry a pocket card
expressing their wishes in an emergency in case they areunable to make their wishes known personally.3 If one ofJehovah’s Witnesses chooses to receive blood or a blood prod-uct, privacy and confidentiality is essential. They are encour-aged to report indiscretions of others,4 so it is essential to dis-cuss the matter with the patient privately, just as you would withany sensitive matter. Visitors and pastoral calls may need to belimited according to patient wishes.2,4 Hospital crisis interventionand support teams should be activated as soon as possible inemergency situations.
A patient may wish to discuss options with trained elders whoform the congregation’s Hospital Liaison Committee and are oncall for this purpose. In addition to advising patients, they canaccess the Hospital Information Services Network, a repositoryof information, including research literature that can be faxed toclinicians.3 It is essential that the patient initiates this contact tomaintain privacy and confidentiality.2,4
Postoperatively, blood conservation is essential. Minimizeblood volume loss from phlebotomy by first ensuring that eachtest is necessary and by using pediatric collection tubes or point-of-care testing where possible.9 Continue with iron and folic acidsupplements and erythropoietin and implement continuousautotransfusion if the patient allows it.
What About the Research?In 1977, the Texas Heart Institute reported on a series of 542
patients who had cardiovascular operations without transfusionsafter the first open heart case in 1964.10 Most deaths were com-plicated cases that presented great risk regardless of transfu-sion status. Anemia was a significant contributing factor in 12deaths, and three deaths were directly attributed to blood loss. In July of 2012, a study from the Cleveland Clinic reports a com-parison between 322 Witnesses who had cardiac surgery with-
Autotransfusion for Jehovah’s Witness Patients
Clinical Update is edited by Patricia Carroll, MS, RN-BC, CEN, RRT, andsupported by an educational grant from Atrium Medical Corporation.
Summer 2012
Continued on page 2
In the LiteratureAnd the Student Shall Lead
The current issue of Dimensions of Critical Care Nursingincludes a report on a pilot study conducted by nursing students toenhance communication between nurses, residents and familiesduring end-of-life (EOL) care. The students reviewed the literature,designed an educational intervention, presented it and assessedthe results. They met their goals relating to improved communica-tion and efficacy in residents’ EOL care. Source: Rose C, Bonn A, MacDonald K, Avila S: Interdisciplinary education ondiscussing end-of-life care. Dimensions of Critical Care Nursing 2012;31(4):236-240. PubMed Citation
Synthesis of Self-Management ProcessResearchers at Yale published a metasynthesis of research
describing processes of self-management in chronic illness in thecurrent issue of Journal of Nursing Scholarship. They identified 3domains: focusing on illness needs, activating resources, and livingwith chronic illness and they group tasks and skills by thesedomains. This superb review provides guidance for nurses planningcare for persons managing a variety of chronic conditions. Source: Schulman-Green D et al.: Processes of self-management in chronic ill-ness. Journal of Nursing Scholarship 2012;44(2):136-144. PubMed Citation
Memory: The Diary We CarryA research study from Paris in the current issue of Critical Care
Medicine describes the benefits of maintaining a diary for criticallyill patients and their families. Entries are made by caregivers andfamily members and can enhance understanding and fill in the gapswhen memory fails under stress. Post-traumatic stress scores post-discharge were reduced for those who had diaries. A detaileddescription allows replication in any ICU.Source: Garrouste-Orgeas M et al: Impact of an intensive care unit diary on psy-chological distress in patients and relatives. Critical Care Medicine2012;40(7):2033-2040. PubMed Citation
How Can Blood Save Your Life?The Watchtower is the official Web site of Jehovah’sWitnesses. This resource provides a detailed explana-tion of their perspectives on blood transfusions.http://www.watchtower.org/e/hb/index.htm
Society for the Advancement of BloodManagementThis organization was founded in 2001 with the beliefthat blood management should be standard of carewith transfusion as an alternative option. This multidis-ciplinary group provides scientific, evidence-basedresources for clinicians and patients alike. The societyprovides some free continuing education, an up-to-date list of literature relating to blood management anda searchable database of blood management centers.http://www.sabm.org
Association for Blood ConservationThis non-profit organization evolved from the NationalAssociation for Bloodless Medicine and Surgery.Members include registered nurses, physicians, perfu-sionists, blood bankers, hospital administrators and laypersons. While the group began as a way to advocatefor persons who declined blood transfusions, the bloodmanagement programs developed can reduce exposureto transfusion risks for all patients. The associationaccredits hospital programs and provides administrativeand practice standards on their site. http://abchq.org
Network for the Advancement of TransfusionAlternativesThis international network was assembled in 1998 topromote and share information about blood conserva-tion and transfusion alternatives. The founding mem-bers wanted a focus on practical strategies, not justacademic discussion. The site provides literaturereviews with NATA commentary, online briefs and otherresources related to blood management.http://www.nataonline.com
Summer 2012
out transfusion and a matched group who accepted blood.6Statistically significant in-hospital complications favoringWitnesses were: reoperation for bleeding or tamponade, periop-erative MI, respiratory failure, hospital LOS, and ICU LOS. Long-term data showed a better one-year survival for Witnesses, butsimilar 20-year survival between the groups.
Comparisons are a challenge because some Witnesses willaccept components, such as cryoprecipitate, that others do not.In addition, surgeons may decline to operate on patients who arehigh risk and refuse blood transfusions. But as we learn moreabout the risks of blood transfusion, techniques and strategiesused for this group of patients may be of benefit to all. Sources1. Watch Tower Bible and Tract Society of Pennsylvania: How Can Blood Save Your Life?Author. New York, New York; 2006. http://www.watchtower.org/e/hb/index.htm2. Tovarelli T, J Valenti: The pregnant Jehovah's Witness: how nurse executives canassist staff in providing culturally competent care. JONA's Healthcare Law Ethics &Regulation 2005;7(4):105-109. PubMed Citation3. Wade P: Treating Jehovah's Witnesses. British Journal of Perioperative Nursing2004;14(6):254-257. PubMed Citation4. Simpson J: Nursing with dignity. Part 9: Jehovah's Witnesses. Nursing Times2002;98(17):36-37. PubMed Citation5. Ferraris VA: Severe blood conservation: benefits and risks. Archives of InternalMedicine 2012; Online First, doi:10.1001/archinternmed.2012.2458 PubMed Citation6. Pattakos G, CG Koch, ME Brizzio, et al.: Outcome of patients who refuse transfusionafter cardiac surgery. Archives of Internal Medicine 2012; Online First, doi:10.1001/archin-ternmed.2012.2449 PubMed Citation
7. Writing Committee of the Governing Body of Jehovah's Witnesses: Questions FromReaders. The Watchtower. October 15, 2000, 1712: 30-31. 8. Nussbaum W, N deCastro, FW Campbell: Perioperative challenges in the care of theJehovah's Witness: a case report. Journal of the American Association of NurseAnesthetists 1994;62(2):160-164. PubMed Citation9. Putney LJ: Bloodless cardiac surgery: not just possible, but preferable. Critical CareNursing Quarterly 2007;30(3):263-270. PubMed Citation10.Ott DA, DA Cooley: Cardiovascular surgery in Jehovah's Witnesses. JAMA1977;238(12):1256-1258. PubMed Citation
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