How to manage a conscious 18-year-old Jehovah's Witness with a contained splenic rupture who refuses blood transfusion (Blood Transfusion) due to religious beliefs?

Management of a Jehovah's Witness Patient with Splenic Rupture

Initial Assessment and Ethical Framework

The attending surgeon must proceed with surgical management of the contained splenic rupture using bloodless techniques, as this represents the best approach to reduce mortality and preserve quality of life while respecting the patient's autonomous refusal of blood transfusion. 1

The situation presents both clinical and ethical challenges:

• The patient has decision-making capacity and has clearly refused blood transfusion
• The contained splenic rupture requires surgical intervention
• The attending surgeon's unwillingness creates a conflict between patient autonomy and provider conscience

Clinical Management Approach

Pre-operative Optimization

1. Assess hemodynamic stability:

   • Monitor vital signs continuously
   • Evaluate for signs of ongoing internal bleeding
   • Maintain adequate intravascular volume with crystalloids/colloids

2. Implement blood conservation strategies:

   • Consider erythropoiesis-stimulating agents if time permits 1
   • Administer intravenous iron supplementation if indicated 2
   • Minimize blood sampling using pediatric tubes 3

Surgical Management

1. Intraoperative blood conservation techniques:

   • Set up cell salvage equipment (acceptable to most Jehovah's Witnesses) 1
   • Implement acute normovolemic hemodilution if acceptable to patient 4
   • Use meticulous surgical technique to minimize blood loss
   • Consider induced hypotensive anesthesia if hemodynamically tolerated 4

2. Splenic preservation approach:

   • Attempt partial splenectomy or splenorrhaphy when possible 1
   • Use hemostatic agents liberally
   • Consider angioembolization if available and acceptable to patient 1

Post-operative Care

1. Close monitoring for bleeding:

   • Frequent hemoglobin checks
   • Vigilant assessment for signs of hemorrhage
   • Early intervention for any deterioration

2. Anemia management:

   • Continue erythropoiesis-stimulating agents
   • Maintain iron supplementation
   • Optimize oxygen delivery (supplemental oxygen)
   • Minimize oxygen consumption (treat fever, pain)

Addressing the Attending Surgeon's Concerns

Clinical Evidence Discussion

1. Present evidence on bloodless surgery outcomes:

   • Studies show comparable outcomes for surgical patients managed without blood transfusions 2, 3
   • Risk-adjusted studies demonstrate that bloodless management is not an independent predictor of adverse outcomes 3

2. Discuss specific splenic trauma management:

   • Guidelines support non-operative management of splenic trauma in hemodynamically stable patients 1
   • Cell salvage is specifically mentioned in guidelines as appropriate for patients who refuse transfusion 1

Ethical Framework

1. Patient autonomy:

   • The patient has decision-making capacity and clear religious convictions
   • Legal and ethical principles support respecting informed refusal 5

2. Professional obligations:

   • The surgeon's duty of care includes respecting patient autonomy
   • Guidelines specifically address management of patients who refuse transfusion 1
   • Transfer of care is appropriate if the surgeon cannot proceed due to moral objections

3. Institutional approach:

   • Implement a "bloodless medicine" protocol 2, 3
   • Ensure availability of surgeons willing to operate without blood transfusion
   • Document discussions thoroughly

Clinical Decision Algorithm

1. If patient remains hemodynamically stable:

   • Proceed with surgical management using bloodless techniques
   • Implement cell salvage if acceptable to patient
   • Consider angioembolization if appropriate

2. If surgeon refuses to proceed:

   • Transfer care to another surgeon willing to respect patient's wishes
   • Document transfer of care and rationale
   • Ensure continuity of care during transition

3. If patient becomes unstable:

   • Reconfirm patient's wishes regarding blood products
   • Implement aggressive non-blood volume resuscitation
   • Expedite surgical intervention with bloodless techniques

Potential Pitfalls and Caveats

• Documentation: Ensure thorough documentation of the patient's informed refusal and understanding of risks
• Consent process: Verify exactly which blood products and components the patient refuses (some Jehovah's Witnesses accept certain fractions)
• Advance planning: Establish institutional protocols for managing patients who refuse transfusion
• Surgeon selection: Identify surgeons willing to operate within patient-directed constraints
• Avoid coercion: Do not attempt to override patient's autonomous decision despite clinical concerns

The evidence strongly supports that with proper preparation and technique, patients who refuse blood transfusion can be safely managed with outcomes comparable to those who accept transfusions 2, 3. The surgeon's ethical obligation is to provide appropriate care within the patient's clearly expressed limitations.