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When blood transfusion isn’t an option

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By: Bonnie L. Schuerger, MSN, RN

Provide safe, culturally sensitive care.

Takeaways:

  • Jehovah’s Witnesses and their scriptural beliefs frequently are challenged within our current healthcare system.
  • Blood transfusion for the Jehovah’s Witnesses patient isn’t an option, but it may be misinterpreted as refusing medical treatment.
  • Nurses have access to ethical, legal, and cultural tools to help honor Jehovah’s Witnesses patient’s human rights.

Providing holistic and compassionate care in the face of complex ethical and legal situations requires that healthcare professionals possess emotional intelligence. Consider, for example, the approximately 1.2 million Jehovah’s Witnesses living in the United States (about 8.4 million worldwide) whose belief system requires them to decline many human blood products, even when facing death.

A common misconception about Jehovah’s Witnesses is that they believe their faith will heal illness and injury. When health issues arise, members of this religion do seek out the best possible medical care for themselves and their families, but they choose providers who specialize in providing care in line with their beliefs. However, when faced with a life-or-death decision that requires a blood or blood product transfusion, many Jehovah’s Witnesses view the experience as a threat to their faith. (See Jehovah’s Witnesses and blood transfusions.)

Jehovah’s Witnesses and blood transfusions

Jehovah’s Witnesses’ beliefs about transfusions are based on biblical texts and perceived risks. Individual members of the faith vary in their choices, so nurses must clearly establish each patient’s preference.

In 1945, Watch Tower Bible and Tract Society, the legal organization of leaders of the Congregation of Jehovah’s Witnesses, concluded that blood transfusions are contrary to divine law. Nearly all Jehovah’s Witnesses refuse transfusions of whole blood, red and white corpuscles, platelets, and plasma. Some also may refuse both natural and recombinant hemoglobin, although positions differ regarding blood-derived products such as albumin, immunoglobulin, and coagulation factors.

For more information and resources on personal decisions individual Jehovah’s Witnesses can make regarding blood products, see the Watchtower Online Library on Blood Fractions and Medical Procedures at wol.jw.org/en/wol/d/r1/lp-e/202006400.

As integral members of the interprofessional healthcare team, nurses must possess empathy, compassion, and nonjudgment. They also must have knowledge of many ethical and legal issues. When caring for Jehovah’s Witnesses, your goals include providing a stress-free, calm, and healing environment to help alleviate patient and family anxiety about blood and blood product transfusions. Meticulous planning and execution, including implementation of the seven pillars of care, can assist you in advocating for individual patient needs. (see Seven pillars.)

Seven pillars

Patient blood management, a patient-centered, evidence-based approach to transfusion, seeks to provide the right care, in the right setting, in the right way, every time. It includes honoring the wishes of patients who decline blood products.

Schwab and colleagues identified seven pillars of care to ensure Jehovah’s Witnesses receive patient-centered care.

  1. Ethical considerations
  2. Legal concerns
  3. Admission documentation and screening
  4. Advance directives
  5. Durable power of attorney
  6. Hospital liaison committees
  7. Compassionate nonjudgmental care

Ethical and legal concerns

Patient rejection of blood or blood product transfusions (even when faced with death) may create an ethical dilemma for healthcare providers, but a mentally competent individual has an absolute moral and legal right to refuse or reject a transfusion. Exceptions include diminished decision-making capacity, a legal intervention, or a legal document that mandates treatment. Most Jehovah’s Witnesses will decline transfusion of whole blood products, but if possible, discuss the specifics alone with the patient. Some will accept a blood transfusion privately.

Schwab and colleagues describe blood management as a patient-centered, evidence-based approach to transfusion that seeks to provide the right care, in the right setting, in the right way, every time. It includes honoring the wishes of patients who decline blood products, which may create feelings of cognitive dissonance in nurses, physicians, and hospital staff. The principle of beneficence requires nurses, physicians, and hospital staff to act for the benefit of the patient and support a number of moral rules that protect and defend the rights of others, prevent harm, and remove conditions that may cause harm. Peyton describes successful care of patients who decline blood products as including respectful dialogue that doesn’t attempt to coerce them into accepting treatment.

Respect for the patient’s autonomy and legal rights requires obtaining informed consent before any medical intervention. Documentation protects both the patient’s right to make decisions about their own healthcare and the professional practice of nurses, physicians, and hospitals.

Admission documentation and screening

Effective care of patients who decline blood transfusion includes helping them to clearly document their specific wishes in a format that both the patient and hospital staff can easily access and understand. Begin this process during admission by clarifying medical and technical issues. Learn which medications (including interferons, clotting factors, RhoGAM, erythropoietin, and tissue adhesives) may contain a blood product and, as needed, consult with the pharmacy for more detailed information. Refer patients to bloodless centers as appropriate. More than 100 such centers, which have integrated principles of bloodless care (including minimizing diagnostic blood loss), exist in the United States. They employ healthcare providers who specialize in bloodless care.

Weeks before a bloodless procedure, physicians may prepare the patient by bolstering the patient’s hematocrit with iron supplements, recombinant products (erythropoiesis-stimulating agents, granulocyte colony–stimulating factors), or I.V. iron or tranexamic acid. The patient meets with physician a few days before the procedure to ensure their hemoglobin is at a safe level.

Many Jehovah’s Witnesses carry a signed and witnessed advance directive and a durable power of attorney for healthcare. In addition to scanning these documents into the patient’s health record, many hospitals provide a form that states the patient declines whole blood, red cells, white cells, platelets, and plasma, as well as a list of additional choices the patient will either accept or refuse.

Advance directive

Advance directives carried by Jehovah’s Witnesses list the blood products and autologous procedures that are and are not acceptable to the individual patient. Include a copy of this document in the patient’s record, and ensure treatment limitations are made clear to all members of the clinical team. As appropriate and to ease patient concerns, work with the local Hospital Liaison Committee for Jehovah’s Witnesses. (See Hospital liaisons.)

Hospital liaisons

The Jehovah’s Witnesses’ worldwide network of more than 1,700 Hospital Liaison Committees (HLCs) provides authoritative information about clinical strategies to avoid blood transfusion and facilitates access to healthcare for patients who are Jehovah’s Witnesses. Hospital liaisons, specially trained Jehovah’s Witnesses elders, offer free consultation services to any physician or hospital administrator with an interest in bloodless medicine. Services include educational presentations, clinical papers, and facilitation of physician-to-physician consultation.

To contact a local HLC representative, visit jw.org/en/medical-library and click “Contact Local Representative.”

Durable power of attorney

A Jehovah’s Witnesses’ legal durable power of attorney for healthcare clearly states the patient’s decision not to accept blood transfusions. It also lists healthcare agents who can be contacted for assistance if needed. These documents are particularly useful when treating a patient who arrives at the hospital unconscious or otherwise unable to meaningfully participate in decision-making. Some durable power of attorney documents allow healthcare agents to override a patient’s written statements if the patient can’t. However, the document carried by many Jehovah’s Witnesses contains the following legal language: “I give no one (including my healthcare agent) any authority to disregard or override my instruction set forth herein.”

Compassionate, nonjudgmental care

Jehovah’s Witnesses’ religious and spiritual beliefs frequently are misinterpreted within the healthcare community, and some providers, including nurses, judge them for their treatment choices. Providing competent and compassionate care requires that nurses be prepared to protect the rights of all patients, including Jehovah’s Witnesses. You can accomplish this by using the ethical and legal tools that support and advocate for Jehovah’s Witnesses’ religious beliefs.

Bonnie L. Schuerger is a clinical nurse educator at Kent State University in Kent, Ohio.

References

Chand NK, Subramanya HB, Rao GV. Management of patients who refuse blood transfusion. Indian J Anesth. 2014;58(5):658-64. doi:10.4103/0019-5049.144680

Fowler J. From staff nurse to nurse consultant: Spiritual care part 8: Jehovah’s Witnesses. Br J Nurs. 2017;26(21):1207. doi:10.12968/bjon.2017.26.21.1207

Joint Professional Advisory Committee. 12.2: Jehovah’s Witnesses and blood transfusion. January 4, 2020. transfusionguidelines.org/transfusion-handbook/12-management-of-patients-who-do-not-accept-transfusion/12-2-jehovah-s-witnesses-and-blood-transfusion

Jorgenson TD, Golbaba B, Guinn NR, Smith CE. When blood is not option: The case for a standardized blood transfusion consent form. ASA Monitor. 2017;81:48-50. pubs.asahq.org/monitor/article/81/6/48/5887/When-Blood-Is-Not-an-Option-The-Case-for-a

Peyton MA. The sanctity of blood: Jehovah’s Witnesses and bloodless medicine. hekint.org/2020/01/29/the-sanctity-of-blood-jehovahs-witnesses-and-bloodless-medicine

Putney LJ. Bloodless cardiac surgery: Not just possible, but preferable. Crit Care Nurse Q. 2007;30(3):263-70. doi:10.1097/01.CNQ.0000278927.44691.8c

Schwab R, Kosoglow M, Hite Philp FH, Suydam E. When transfusion is not an option—The challenges and rewards. Critical Care Nurs Q. 2018;41(4):347-55. doi:10.1097/CNQ.0000000000000219

Stanford’s Children’s Health. Pediatric bloodless cardiac surgery program: What to expect. https://www.stanfordchildrens.org/en/service/bloodless-surgery/what-to-expect

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