Proceedings From the Society for Advancement of Blood Management Annual Meeting 2017: Management Dilemmas of the Surgical Patient-When Blood Is Not an Option.

Vigilance is essential in the perioperative period. When blood is not an option for the patient, especially in a procedure/surgery that normally holds a risk for blood transfusion, complexity is added to the management. Current technology and knowledge has made avoidance of blood transfusion a realistic option but it does require a concerted patient-centered effort from the perioperative team. In this article, we provide suggestions for a successful, safe, and bloodless journey for patients. The approaches include preoperative optimization as well as intraoperative and postoperative techniques to reduce blood loss, and also introduces current innovative substitutes for transfusions. This article also assists in considering and maneuvering through the legal and ethical systems to respect patients' beliefs and ensuring their safety.

Justice and Respect for Autonomy: Jehovah's Witnesses and Kidney Transplant.

That Jehovah's Witnesses may refuse lifesaving blood transfusions is a morally accepted feature of contemporary medical practice. The principle of respect for autonomy supports this, and there is seldom reason to interfere with this choice because it rarely harms another individual. Advances in surgical technique have made it possible for transplant surgeons to perform bloodless organ transplant, enabling Jehovah's Witnesses to benefit from this treatment. When the transplant organ is a directed donation from a family member or friend, no ethical dilemma arises. However, when a Jehovah's Witness cannot identify a living donor and wishes to be listed for organ transplant, the transplant team may face an ethical dilemma. On the one hand, it wishes to provide care to the patient that is compatible with her or his preferences. On the other hand, the team may wonder if it is fair to other patients who need an organ and will accept blood transfusion to include the Jehovah's Witness patient on a waiting list for a donated organ. If the Jehovah's Witness patient is listed and receives an organ, then a patient who also needs an organ, and who is willing to accept all care to optimize the success of the transplant, may be denied an organ. To frame the ethical dilemma outlined above we present an anonymized case of a Jehovah's Witness woman in urgent need of a kidney, who was referred to one of the authors' institution's transplant center. We review the evolution of the Jehovah's Witness position on blood transfusion and the medical community's efforts to provide care that accommodates this religious commitment. If Witnesses are to be denied transplant in the name of justice, there must be an ethically sound reason. We identify two rationales in the literature: (1) this allocation is unacceptable because it will cost lives; (2) resources should be allocated to patients who comply with the standard of care. We argue that neither apply to this dilemma. We also emphasize the importance of examining the data on outcomes of transplant with and without transfusion. Our interpretation of the published data on transplant without transfusion is that the outcomes are similar. We conclude that, in the absence of data that resources are risked, it is not ethical to refuse to include a Jehovah's Witness patient on a waiting list for an organ. Finally, we reflect on the heterogeneity in transplant institutes' polices for accepting Jehovah's Witness patients.

Religious Identity and Health Inequalities in Canada.

In the past few decades, most new immigrants to Canada have originated from non-Christian countries. During the same period, the unaffiliation rates have sharply increased in Canada. This paper investigates whether there are any health inequalities associated with religious identity, including also the individuals who do not identify with organized religion in the analysis. The study uses the Canadian General Social Survey of 2012 (N = 23,093), focused on Caregiving and Care-receiving. Employing multivariate regression analysis and controlling for a large set of characteristics inclusive of the degree of religious commitment, individuals who identify as Protestant are found at a physical and mental health advantage, compared with Roman Catholics and most other groups. On the other hand, individuals who identify as Jehovah's Witnesses are found at a considerable physical health disadvantage. Among the unaffiliated individuals, those who have retained some ties with organized religion without formally identifying with it are found at a mental health disadvantage compared with all religious groups, as well as the secular individuals who are strictly committed to their nonreligious views. Possible causes and various implications are discussed.

Responsabilidade penal de pais testemunhas de Jeová por recusa de tratamento médico em crianças e adolescentes / Criminal responsibility of parents Jehovah's Witnesses for refusing medical treatment to children and adolescents

Examina-se, neste estudo, decisão da Sexta Turma do Superior Tribunal de Justiça no Habeas Corpus n. 268.459/SP, proferida em 02 de setembro de 2014, que discutiu a responsabilidade penal dos pais por recusa de transfusão sanguínea em paciente menor de idade. A metodologia utilizada foi do tipo documental-bibliográfico, com pesquisa pura de abordagem qualitativa, descritiva e exploratória. O referido habeas corpus aborda o caso de uma adolescente de 13 anos, que deu entrada no hospital em virtude de grave estado de saúde provocado por anemia falciforme. O quadro clínico da paciente exigia, com urgência, transfusão de sangue para salvaguardar sua vida. Todavia, seus pais, por razão de convicção religiosa da seita Testemunhas de Jeová, assinaram declaração recusando o referido tratamento, dando, assim, ensejo ao óbito da menor impúbere. O fato gerou precedente judicial no STJ, permitindo ao médico fazer a transfusão de sangue sempre que o paciente menor de idade estiver em iminente perigo de morte, independentemente da escolha religiosa de seus representantes legais. Conclui-se que o caso no Habeas Corpus n. 268.459/SP é marcado por uma colisão entre o direito à vida da criança e do adolescente e o direito à liberdade de consciência e de crença dos pais, que foi ponderada pela Sexta Turma do STJ.(AU)

This study examines the decision of the Sixth Chamber on Brazil's Superior Court of Justice (SCJ) in Habeas Corpus 268.459/SP, issued on September 2, 2014, which discussed the criminal responsibility of parents for refusing a blood transfusion to a minor patient. The methodology used was of the documentary-bibliographic type, with pure research of qualitative, descriptive and exploratory approach. The aforementioned habeas corpus addresses the case of a thirteen- year-old girl who was admitted to the hospital due to a serious health condition caused by sickle cell anemia. The patient's clinical condition urgently required blood transfusion to safeguard her life. However, her parents, due to their belief in Jehovah's Witness cult, signed a declaration that refused such treatment, thus leading to the girl's death. This fact gave rise to a judicial precedent in the SCJ, allowing doctors to conduct blood transfusions whenever minor patients are in imminent danger of death, regardless of the religious choice of their legal representatives. It is concluded that the Habeas Corpus case is marked by a collision between the right to life of the child and the adolescent and the right to freedom of conscience and belief of the parents, which was considered by the Sixth Chamber of the SCJ.(AU)

Health care reform and Diagnosis Related Groups in Germany: The mediating role of Hospital Liaison Committees for Jehovah's Witnesses.

Resulting from health care reform in Germany that was implemented in 2003-2004, a new medical classification system called the "Diagnosis Related Groups" (DRGs) was introduced in hospitals. According to the media, social scientists, and a few physicians interviewed in this study the policy negatively transformed the German health care system by allowing the privatization of the hospital sector consistent with the neoliberal health care model. Allegedly, this privileged economic values over the quality of health care and introduced competition between hospitals. Nevertheless, members of the Hospital Liaison Committees (HLCs) of Jehovah's Witnesses argued that the DRGs system could be used to the advantage of Jehovah's Witness (JW) patients. HLCs often assist in the patient's search by providing names of physicians that would be willing to refrain from blood transfusions. This article draws from nine months of ethnographic research with Jehovah's Witnesses, including members of the HLCs, carried out primarily in Berlin between 2010 and 2012. By focusing on JWs, whose refusal of blood transfusions is often exemplified as particularly difficult for the biomedical profession, it addresses the "unintended" consequences of the introduction of DRGs into the German health care system that remain unexplored by health and social science scholarship. It argues that although JWs have long been associated with the judicialization of religious freedom globally, they do not equally engage in the judicialization of health in countries such as Germany. The reason for this is embedded not only in health care policy that favors mediation over medical malpractice litigation. It also results from the synergy of health care reforms that prioritize standardizing and economizing measures such as DRGs as well as practices implemented by Patient Blood Management programs that JW institutions, such as HLCs, have tapped into.

Intraoperative Anemia and Single Red Blood Cell Transfusion During Cardiac Surgery: An Assessment of Postoperative Outcome Including Patients Refusing Blood Transfusion.

OBJECTIVES: Increasing evidence suggests benefits from restrictive red blood cell transfusion (RBC) thresholds in major surgery and critically ill patients. However, these benefits are not obvious in cardiac surgery patients with intraoperative anemia. The authors examined the association between uncorrected hemoglobin (Hb) levels and selected postoperative outcomes as well as the effects of RBCs. DESIGN: Cohort study with prospectively collected data from a cardiac surgery registry. SETTING: A major cardiac surgical hospital within the Netherlands, which is also a referral center for Jehovah's Witnesses. PARTICIPANTS: Patients (23,860) undergoing cardiac surgery between 1997 and 2013. INTERVENTIONS: Comparisons were done in patients with intraoperative nadir Hb<8 g/dL and/or an Hb decrease ≥ 50%. Comparison (A) between Jehovah's Witnesses (Witnesses) and matched non-Jehovah's Witnesses (non-Witnesses) transfused with 1 unit of RBC, and comparison (B) between patients given 1 unit of RBC intraoperatively versus matched non-transfused patients. MEASUREMENTS AND MAIN RESULTS: Postoperative outcomes were myocardial infarction, renal replacement therapy, stroke, and death. With propensity matching, the authors optimized exchangeability of the compared groups. Adverse outcomes increased with a decreasing Hb both among Witnesses and among non-Witnesses. The incidence of postoperative complications did not differ between Witnesses and matched non-Witnesses who received RBC (adjusted odds ratio 1.44, 95% confidence interval 0.63-3.29). Similarly, postoperative complications did not differ between patients who received a red cell transfusion and matched patients who did not (adjusted odds ratio 0.94, confidence interval 0.72-1.23). CONCLUSION: Intraoperative anemia is associated with adverse outcomes after cardiac surgery, and a single RBC transfusion does not seem to influence these outcomes.

Use of a simple, inexpensive device for collection of blood during acute normovolaemic haemodilution in a Jehovah's Witness patient.

Postoperative anaemia is a concern for patients who refuse blood products or have rare blood types. Acute normovolaemic haemodilution (ANH) is a potential solution for these challenging populations. However, protocols for ANH provide limited detail on preparation of blood collection systems. This report describes a novel protocol for ANH and an example of a patient who clearly benefited from ANH.

Costs and outcomes after cardiac surgery in patients refusing transfusion compared with those who do not: a case-matched study.

BACKGROUND: Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovah's Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion. STUDY DESIGN AND METHODS: A retrospective database review was performed to find all patients having cardiac surgery who refused blood products from January 2005 to July 2012 at Duke University Medical Center. These 45 patients were closely matched 1:2 with controls who accepted transfusion based on characteristics likely to influence transfusion. Cost from day of surgery to hospital discharge and other outcome data (length of stay [LOS], discharge hemoglobin [Hb], acute kidney injury) were analyzed retrospectively. RESULTS: Forty-five Witnesses having cardiac surgery were temporally matched to two controls having the same surgery. Median euroSCORE was the same in both groups (6.0, p = 0.9981). In the matched-pairs comparison of cost, there was no significant difference in total cost for Witnesses and controls. There was no difference in intensive care unit LOS (median, 1 day, both groups) or total LOS (median, 9 days for Witnesses vs. 7 days for controls). Mean Hb at discharge was higher in Witnesses than in controls (11.7 g/dL vs. 9.8 g/dL, p < 0.001). Thirty-day mortality was zero in both groups. CONCLUSION: Utilizing applicable blood conservation measures, cardiac surgery may be performed with similar outcomes and cost from day of surgery to discharge compared to controls in select patients without blood transfusion.

Aspectos legales de la transfusión de hemoderivados en el paciente crítico pediátrico hijo de padres Testigos de Jehová, a propósito de un caso mediáticamente relevante / Legal aspects of blood-derived transfusion in a pediatric critical patient whose parents are Jehova Witness: with regard to a medically relevant case

Caso: en el mes de agosto del año 2013, se dio lugar un caso en la ciudad de Guayaquil, que llamó la atención a los medios de comunicación. Una jueza, dictaminó una orden judicial (medida cautelar) para la administración de sangre a un neonato ingresado en Unidad de Cuidados Intensivos Neonatales, que requería transfusión sanguínea urgente y que era hijo de padres que negaban la transfusión al menor de edad aduciendo motivos religiosos. Este artículo tiene como objetivos verificar fuentes sobre el caso y realizar una revisión bibliográfica sobre los fundamentos religiosos, bioéticos y legales que sustenten el evento. Para el desarrollo del mismo se realizó entrevistas tanto a la Jueza involucrada, como al procurador jurídico de la Congregación de los Testigos de Jehová del Ecuador, al Asesor Jurídico de la Jefatura de la DINAPEN (Dirección Nacional de la Policía especializada en Niños, Niñas y Adolescentes), y al Director Nacional Tutelar de la Defensoría del Pueblo del Ecuador. Este reporte de caso, además cuenta con una revisión actualizada del tema con el fin de esclarecer las condiciones en las que se debe recurrir a instancias judiciales ante la negativa de los padres de transfusión a menores de edad en condiciones críticas.

Case: in august 2013, a particular medical case called the attention of the Media in the city of Guayaquil. A Judge granted a judicial order (interim measure) for blood transfusion to a newborn child who was an inpatient in the Newborn Intensive Care Unit and needed the treatment urgently. The parents of the Child refused the blood transfusion due to their religious beliefs. The objectives of the present article are to share the interviews of the sources of the case and confirm the event. In addition, a review of the religious, bioethical and legal issues behind the event has been portrayed. Interviews to the Judge involved, the Jehovah's Witness of Ecuador Attorney, the Legal Adviser of DINAPEN (Police Specialized in Children National Management Office), and the National Tutelary Attorney of the Public Defense Office of Ecuador were performed. Furthermore, the article will set the procedure in which legal action shall be sought for the administration of blood transfusions in critical situations when parents deny a blood transfusion in children.

Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

BACKGROUND: Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. STUDY DESIGN AND METHODS: We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. RESULTS: Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. CONCLUSIONS: Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

[Is the claiming of costs justifiable in Jehovah's witness surgical patients after healthcare that is not part of the public health system?]. / ¿Es justificable el reintegro del gasto en enfermos quirúrgicos testigos de Jehová tras asistencia sanitaria ajena al sistema público de salud?

INTRODUCTION: Jehovah's witnesses refuse blood transfusions. The conflict arises when the patient, entitled to public health treatment, come to surgical centres without blood, to later claim the costs incurred. OBJECTIVES: To analyse the legal claims for the refunding of costs by Jehovah's witnesses treated outside the public health system. To make a cost comparison regarding this, using Diagnosis Related Groups (DRGs) in a similar hypothetical healthcare model and equal to a stay in our hospital. MATERIAL AND METHODS: A retrospective study was made of the High, Constitutional, and Supreme Court rulings. A cost analysis was made using the clinical information obtained in the rulings, to process this in the DRG in our hospital using 3MHealth Information Systems. RESULTS/CONCLUSIONS: The State is not obliged to finance religious aspects or those outside the general interest. The establishment of working protocols would avoid ethical conflicts. There are very difficult to justify differences in the costs demanded, 431,001.66 €, and compared to a model with an equal stay, 397,404.48 €.

Opening the black box of ethics policy work: evaluating a covert practice.

Hospital ethics committees (HECs) and ethicists generally describe themselves as engaged in four domains of practice: case consultation, research, education, and policy work. Despite the increasing attention to quality indicators, practice standards, and evaluation methods for the other domains, comparatively little is known or published about the policy work of HECs or ethicists. This article attempts to open the "black box" of this health care ethics practice by providing two detailed case examples of ethics policy reviews. We also describe the development and application of an evaluation strategy to assess the quality of ethics policy review work, and to enable continuous improvement of ethics policy review processes. Given the potential for policy work to impact entire patient populations and organizational systems, it is imperative that HECs and ethicists develop clearer roles, responsibilities, procedural standards, and evaluation methods to ensure the delivery of consistent, relevant, and high-quality ethics policy reviews.

Clinical benefits and cost-effectiveness of allogeneic red-blood-cell transfusion in severe symptomatic anaemia.

BACKGROUND: It is well known that blood transfusion is life-saving, but also that it carries a serious risk of transmitting viral infections. Introduction of new methods of testing for transmissible diseases, blood banking and dispatch regulations has considerably increased the cost of blood products. However, the clinical benefits and cost-effectiveness of allogeneic red-blood-cell (ARBC) transfusion remain assumed yet undetermined. We assessed the clinical benefits and cost-effectiveness of ARBC transfusion in severe anaemia. METHODS: This was a multicenter observational study comparing Jehovah's Witness (JW) patients with matched ARBC-transfused patients. Inclusion criteria were age ≥15 years and severe anaemia (haemoglobin ≤ 80 g/l). Two JW patients with palliative care cancer and five JW patients with haemoglobin (Hb) concentration between 70·1 and 80 g/l, mild symptoms of anaemia and Auckland Anaemia Mortality Risk Score of 0-3 were excluded. RESULTS: The entry criteria were met by 103 JW patients and the same number of patients treated with ARBC transfusion. ARBC transfusion reduced mortality by 94%, shock by 88%, gastrointestinal bleeding by 81%, infective complications by 81%, cardiac arrhythmia by 96%, angina by 86%, ischaemic myocardial injury by 81%, acute/acute on chronic renal failure by 66%, neurologic complications by 92%, delirium by 76%, depression by 91% and syncopal episodes by 95%. The incremental cost-effectiveness ratio of ARBC transfusion was 2011 US$22 515 for death prevented. CONCLUSION: ARBC transfusion in anaemic patients is clinically beneficial and cost-effective.

When a patient refuses life-saving care: issues raised when treating a Jehovah's Witness.

Patients who are Jehovah's Witnesses frequently cross the path of nephrologists when they are acutely ill in the intensive care unit and stable in the long-term setting. It is important that we as a group have a rudimentary understanding of their philosophy about blood transfusion so that we can be proactive in their management. We use a case as a launching point to discuss the origins of the faith and the decision to refuse blood, as well as potential therapeutic strategies that can be used to improve the care of these patients. Improvement in our understanding as physicians will facilitate a more productive conversation with our patients about a complex and emotional issue.

[Cell salvage]. / Maschinelle Autotransfusion.

With increasing demands for blood transfusions, the costs and shortages, clinically relevant risks and doubts on the efficacy, blood conservation is an important issues. Among the available methods cell salvage is of great importance as it has proven effective and safe. The high availability and cost efficacy allows fast processing of at least half of the lost red blood cells. The method has wide applications in cardiac and vascular surgery, in abdominal and transplantation surgery, in orthopedics and emergency medicine, in massive hemorrhage and for Jehovah's Witnesses, and by the use of blood irradiation also in cancer surgery. Cell salvage provides autologous, washed, unstored red blood cells with unimpaired function and viability, avoiding immunological reactions and storage damage, for optimal hemotherapy. No restrictions in the indication for transfusion are necessary, thus allowing real therapy of anemia. The high quality of salvaged blood should be assured by a quality management including quality controls.