How to manage a Jehovah's Witness (JW) patient in an emergency situation requiring blood transfusion?

From the Guidelines

In an emergency situation requiring blood transfusion for a Jehovah's Witness patient, immediately consult the hospital ethics committee and legal counsel while exploring bloodless alternatives, as recommended by the most recent guideline from the European Society of Intensive Care Medicine 1. When dealing with a Jehovah's Witness patient in an emergency situation, it is crucial to first determine if the patient has an advance directive or medical power of attorney that addresses blood products.

• For conscious patients, discuss their specific objections, as some may accept certain blood fractions or components while refusing whole blood.
• Medical alternatives include erythropoietin to stimulate red blood cell production, iron supplementation, vitamin K, and hemostatic agents like tranexamic acid, as suggested in the management of massive haemorrhage 1.
• Volume expanders such as Ringer's lactate or colloid solutions can help maintain blood pressure.
• Cell salvage techniques that collect, filter, and return the patient's own blood may be acceptable to some Witnesses, as noted in the guidelines for autologous transfusion 1. If the patient is unconscious without clear directives and immediate transfusion is life-saving, physicians may need to proceed with transfusion under emergency exception principles, though this varies by jurisdiction, and it is essential to follow the principles of positive patient identification and administrative checks 1. The ethical conflict arises from balancing respect for religious autonomy against the medical duty to preserve life, requiring careful, compassionate communication throughout the process, and considering the current evidence for management of bleeding ICU patients 1.

From the Research

Encountering Jehovah's Witnesses in Emergency Situations

• In emergency situations that require blood transfusions, it is crucial to understand the patient's wishes and beliefs, including those of Jehovah's Witnesses who typically refuse blood transfusions.
• According to 2, the standard hemoglobin transfusion threshold was 10 g/dL, but recent literature has shown a hemoglobin transfusion threshold of 7 g/dL to be safe in certain settings.
• In cases where a Jehovah's Witness patient requires a blood transfusion, it is essential to consider alternative treatments and to discuss the risks and benefits with the patient or their representative.
• Studies such as 3 and 4 discuss the use of crystalloids and colloids in fluid resuscitation, which may be relevant in emergency situations where blood transfusions are not an option.

Alternative Treatments

• Crystalloids and colloids can be used as alternative fluids for resuscitation, as discussed in 3 and 5.
• The choice of fluid depends on various factors, including the patient's condition, the severity of blood loss, and the availability of blood products.
• According to 6, successful emergency transfusions require early recognition and activation of resources to minimize treatment delays, and the initial goals should focus on replacement of blood in a balanced fashion.

Considerations for Jehovah's Witness Patients

• When encountering a Jehovah's Witness patient in an emergency situation, it is essential to respect their wishes and beliefs regarding blood transfusions.
• Alternative treatments, such as the use of crystalloids and colloids, should be considered and discussed with the patient or their representative.
• Studies such as 2 and 4 provide guidance on the use of alternative fluids and the importance of goal-directed fluid resuscitation in emergency situations.