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Management of Patients Who Refuse Blood Transfusion


A doctrine introduced in 1945 by Jehovah’s Witnesses teaches that the Bible prohibits the consumption, storage, and transfusion of human blood (Genesis 9:3, 4 and Acts 15:19, 20). The Watch Tower Bible and Tract Society of Pennsylvania have issued many doctrines since that time, citing that “blood is sacred to God,” and “even in the case of an emergency, it is not permissible to sustain life with transfused blood.” These beliefs stem from the interpretation of Biblical scriptures. Many Jehovah’s Witnesses carry medical directive “No Blood” cards, stating that blood transfusions are unacceptable. The use of blood derivatives, however, is not specifically prohibited, and the Watch Tower encourages members to personally decide whether accepting these component fractions violates the doctrine(s). Examples of potentially accepted blood product derivatives include cryoprecipitate, albumin, immunoglobulin therapy, human- derived clotting factor concentrates, and interleukins. Recombinant proteins (e.g., recombinant factor VIIa) are generally accepted by Jehovah’s Witnesses, as are blood substitutes (hemoglobin-based oxygen carriers) ( Fig. 56.1 ).

Figure 56.1
Blood components and fractions.

Reproduced from Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18 (2), 105–116, with permission from Elsevier.

While standard transfusions are unacceptable, there are some related procedures that are not specifically prohibited. These include plasma exchange, dialysis, intraoperative blood salvage, hemodilution, blood donation strictly for the purpose of further fractionation of components, and transfusion of autologous blood as long as a continuous circuit with the patient remains. Transfusion of preoperatively donated autologous blood is, however, typically prohibited, due to the belief that blood should not be taken out of the body and stored ( Table 56.1 ).

Table 56.1
Jehovah’s Witness Religious Position on Medical Therapy
Bodnaruk, Z. M., Wong, C. J., & Thomas, M. J. (2004). Meeting the clinical challenge of care for Jehovah’s Witnesses. Transfus Med Rev, 18 (2), 105–116, with permission from Elsevier.
Acceptable Treatment

  • Most surgical and anesthesiological blood conservation measures (e.g., hemostatic surgical instruments, controlled hypotension regional anesthesia, minimally invasive surgery, meticulous surgical hemostasis)

  • Most diagnostic and therapeutic procedures (e.g., phlebotomy for laboratory testing, angiographic embolization)

  • Pharmacologic agents that do not contain blood components or fractions such as the following:

    • Drugs to enhance hemostasis (e.g., tranexamic acid, epsilon-aminocaproic acid, aprotinin, desmopressin, recombinant factor VIIa, conjugated estrogens)

    • Hematopoietic growth factors and hematinics (e.g., albumin-free erythropoietin, iron)

    • Recombinant products (e.g., albumin-free coagulation factors)

    • Synthetic oxygen therapeutics (e.g., perfluorochemicals)

    • Non–blood volume expanders (e.g., saline, lactated Ringer’s, hydroxyethyl starches)

Personal Decision (Acceptable to Some, Declined by Others)

  • Blood cell salvage a (intraoperative or postoperative autotransfusion)

  • Acute normovolemic hemodilution a

  • Intraoperative autologous blood component sequestration a (including intraoperative plateletpheresis, preparation of fibrin gel, platelet gel, platelet-rich plasma)

  • Cardiopulmonary bypass b

  • Apheresis b

  • Hemodialysis b

  • Plasma-derived fractions (e.g., immune globulins, vaccines, albumin, cryoprecipitate c )

  • Hemostatic products containing blood fractions (e.g., coagulation factor concentrates, prothrombin complex concentrate, fibrin glue/sealant, hemostatic bandages containing plasma fractions, thrombin sealants)

  • Products containing plasma-derived blood fractions such as human serum albumin (e.g., some formulations of erythropoietin, streptokinase, G-CSF, vaccines, recombinant clotting factors, nuclear imaging products)

  • Products containing a blood cell–derived fraction

  • Epidural blood patch

  • Blood cell scintigraphy (e.g., radionuclide tagging for localization of bleeding)

  • Peripheral blood stem cell transplantation (autologous or allogeneic)

  • Other transplants (organ, HSC [hematopoietic stem cell], bone)

Unacceptable Treatment

  • Transfusion of allogeneic whole blood, red blood cells, white cells, platelets, or plasma

  • Preoperative autologous blood donation

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

b Circuits not primed with allogeneic blood.

c Cryoprecipitate suspended in 0.9% sodium chloride injection (USP) diluent.

The right of a competent adult to refuse consent for medical treatment is accepted, and documentation of refusal for transfusion should be placed in the medical record. Electronic medical record and laboratory information systems may be useful in preventing blood from being inadvertently ordered or transfused to a non-consenting patient. Worst-case scenario discussions should be held with patients who refuse blood products, and documentation to this effect should be included in the medical record; some clinicians opt to have patients sign the notes stating that these discussions were held. Forcing a non-consenting patient to receive a transfusion unwillingly can be viewed as battery, and a Jehovah’s Witness who accepts a transfusion can be spiritually cut off from a community of family and friends.

Trauma

Situations of trauma are difficult, in that medical directive cards may not be immediately available. If there is any doubt in a clinician’s mind as to the wishes of the patient or as to what is legally appropriate, it is recommended that the clinician treat per the accepted standards of care until legal documentation is available.

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