What is the most appropriate next step for a patient in the emergency room with severe anemia (low hemoglobin) who refuses packed red blood cells (PRBCs) due to religious reasons?

Management of Patient Refusing Blood Transfusion for Religious Reasons

The most appropriate next step is to have the patient sign a refusal to treat form (informed refusal documentation) after ensuring they understand the risks of refusing transfusion, including death from severe anemia. 1

Legal and Ethical Framework

Competent adult patients have an established right to refuse medical interventions, even when those interventions are immediately lifesaving. This right applies directly to situations like a Jehovah's Witness refusing blood transfusion in the face of life-threatening hemorrhage. 1 Unless the patient's decision-making capacity is impaired or their refusal constitutes a threat to public health, their right to refuse is virtually unlimited. 1

Step-by-Step Approach

1. Confirm Decision-Making Capacity

• Assess whether the patient has intact cognitive function and understands the consequences of refusing transfusion 1
• Verify the patient comprehends that hemoglobin of 5.9 g/dL represents severe, life-threatening anemia
• Document this assessment clearly in the medical record

2. Informed Refusal Discussion

• Explain explicitly that without transfusion, the patient faces significant risk of death, organ failure, and cardiovascular collapse 1
• Discuss that at hemoglobin 5.9 g/dL, compensatory mechanisms (increased cardiac output, enhanced oxygen extraction) may fail to maintain adequate tissue oxygenation 1
• Document that the patient understands these risks and still refuses

3. Document Refusal Formally

• Have the patient sign an informed refusal form that documents their understanding of risks and their voluntary decision to decline PRBCs 1
• This protects both the patient's autonomy and the healthcare team legally
• The documentation should specify what was refused (PRBCs) and what risks were explained

4. Explore Alternative Management Strategies

• Implement a bloodless medicine protocol immediately 1
• Administer intravenous iron if time permits and the patient is not actively bleeding 1
• Consider erythropoietin therapy for longer-term management, though this will not address the acute crisis 1
• Optimize oxygen delivery through supplemental oxygen, maintain normovolemia with crystalloid fluids 1
• Minimize further blood loss by avoiding unnecessary phlebotomy 1

What NOT to Do

Do Not Discharge the Patient

• Discharging a patient with hemoglobin 5.9 g/dL would be abandonment and medically inappropriate
• The patient requires ongoing monitoring and supportive care even without transfusion

Do Not Seek Consent from Family Members

• Talking to the patient's wife separately to obtain consent violates the competent patient's autonomy 1
• Only the patient can make this decision if they have decision-making capacity
• Family members cannot override a competent adult's refusal

Do Not Order FFP

• Fresh frozen plasma does not treat anemia and will not raise hemoglobin 1
• FFP is indicated for coagulopathy correction, not oxygen-carrying capacity 1

Do Not Ask Supervising Physician to Discuss with Family

• This circumvents the patient's autonomy and is ethically inappropriate 1
• The supervising physician should discuss with the patient, not bypass them

Critical Monitoring

• Monitor for signs of critical anemia including altered mental status, chest pain, severe dyspnea, hemodynamic instability 1
• Serial hemoglobin measurements to track trajectory 2
• Continuous cardiac monitoring given the risk of myocardial ischemia at this hemoglobin level
• Assess for ongoing bleeding that might be surgically correctable

Common Pitfalls

• Failing to document informed refusal adequately - this leaves the healthcare team vulnerable and doesn't respect the shared decision-making process 1
• Assuming family can override the patient's decision - they cannot if the patient is competent 1
• Abandoning the patient by discharge rather than providing maximal supportive care within their wishes 1
• Not exploring bloodless medicine alternatives that may be acceptable to the patient 1