A patient enters a surgical office in need of a major operation. He is seeking a third medical opinion. Is it because he is unsure of his diagnosis? No, he’s a Jehovah’s Witness, and the previous surgeons refused to treat him without his consenting to a blood transfusion.

Most nurses have seen similar scenarios in their own practice settings. Nevertheless, patients who choose to decline a treatment often leave their nurses perplexed and frustrated. Without question, this situation can be complicated for both patient and caregiver. However, as nurses, we should try to understand these patients’ quandaries. They may be facing a critical illness but have the added stress of someone’s encouraging them to accept a treatment against their most fundamental beliefs. But the refusal of blood is no longer just a religious issue. For both religious and secular reasons, many people of all faiths and persuasions are looking for alternatives.

A feared therapy of last resort

When given the option, most people do not want a blood transfusion because the general public is aware of the associated dangers, such as viral infections. The current estimate of HIV transmission in blood that tests negative initially is one in 2,135,000.¹ Hepatitis C virus transmission is reportedly one of every 1,935,000 units of blood transfused; bacterial contamination occurs in about one of every 33,000 units of platelet products transfused; and mortality caused by transfusion errors is estimated to be one of every 6,000 transfused units.¹ In addition, the evidence points to the fact that blood transfusions negatively impact immune system response and may contribute to an increased risk for cancer recurrence, postoperative infection, virus activation, and multiple organ failure.² The urgency to ensure blood safety and supply has never been greater.

Shocking media reports of negligence and misconduct in blood banks have only fueled public fear. As Jeffrey McCullough, MD, a professor at the University of Minnesota and editor of the journal, Transfusion, puts it, “If red blood cells were a new drug today, it would be very difficult to get it licensed.”³

Short supply

The general public is frequently made aware of the need for blood donors, especially during times of low reserves, such as vacation and holiday seasons. There are reasons to believe that such blood shortages will persist. On the supply side, the younger generation — a potential pool of donors — has embraced tattooing and body piercing, risky practices that may defer them from donating blood for one year. Persons who have acupuncture may also be ineligible to donate blood for one year, as may international travelers. Ironically, anyone who has received a blood transfusion is ineligible as a donor for 12 months because of the possibility of transmitting an infectious disease that was contracted from a transfusion. In the United States 66 million potential blood donors are excluded as ineligible.

The American Red Cross has reportedly experienced a drought due to this lack of volunteer blood donors. Only 5% of eligible donors do currently give blood. The demand for banked blood, however, marches on as baby boomers compete for the blood supply as they age and need more surgical procedures. The risk of blood loss is increased  during procedures common to this age group, such as joint replacements and cardiac surgery.

Refusal based on faith

Jehovah’s Witnesses unequivocally refuse blood transfusions in all circumstances.⁴ They interpret the Bible literally and have found more than 400 biblical passages to support this practice. The command to abstain from blood, whether by oral or parenteral administration, supercedes any emergency situation.

Although red and white blood cells, platelets, plasma, and whole blood are forbidden, some Jehovah’s Witnesses feel that their consciences will permit them to accept some minor blood fractions, which are listed in the sidebar entitled “Blood Fractions Acceptable to Some Jehovah’s Witnesses.” The reasoning behind their acceptance is that these components move between the circulatory systems of a woman and her fetus during pregnancy.⁵ In recognizing that two separate individuals may “naturally” share these components, some deduce that it is then allowable to accept them in much the same way as any other medication or treatment.

As with minor blood fractions, some Jehovah’s Witnesses feel comfortable consenting to autologous, nonstored blood if the equipment is set up in a manner that allows for a continuous circuit. Thus, the equipment is viewed as an extension of the person’s own circulatory system. Equipment used to create extracorporeal circuits includes cell savers and heart-lung bypass or dialysis machines. These circuits must be connected to patients at all times at both ends of the loop, cannot be primed with blood or blood products, and cannot allow more than a brief interruption of blood flow. For example, a chest tube draining mediastinal blood must be connected directly to the patient’s IV line. However, this consent does not extend to the storage of a Jehovah’s Witness’s own blood in a blood bank for future use (autologous predonation). That practice is prohibited because the blood has been removed from contact with the circulation and is no longer part of the person; it should not be accepted back into the body.⁶

In addition to many physicians and researchers, Jehovah’s Witnesses have been instrumental in the development and proliferation of bloodless care. A department exists at the Watchtower Society’s International Headquarters for the purpose of furthering bloodless education.

Within local communities, hospital liaison committees have been established to assist members of the organization and physicians who need information or guidance.

How is bloodless care possible?

While every healthcare facility that practices bloodless or transfusion-free care does so according to its individualized policies and procedures, the cornerstone of successful bloodless care is an organized approach. Providers need to assess and treat patients holistically, taking both physical and spiritual well-being into consideration. A few key practices universal to transfusion-free care are conservation, prompt treatment, minimally invasive procedure choices, and maximizing a patient’s own blood supply.

Conservation: First and foremost, care should be taken to conserve a patient’s own blood by limiting the amount of laboratory testing that uses blood specimens. One helpful tool is a flow sheet that requires every provider to document every ordered blood test with a signature. Providing a quick, comprehensive summary of what testing has been done can prevent duplicate tests and reminds caregivers how much blood has already been lost. If a particular blood-test result won’t change the treatment plan, blood should not be drawn. Blood that is not drawn doesn’t need to be replaced. In addition, microsampling can help. This technique can be as simple as using pediatric (or smaller) tubes to obtain samples, or as elaborate as specialized microsampling equipment. Many devices are marketed today that allow laboratory analyses to be performed on smaller amounts of blood. Several panels can be performed on a single drop of blood. Some equipment requires only passing the blood through specialized tubing to acquire results. This blood can then be returned to the patient. This technique is particularly valuable in the care of premature newborns.

Transfusion of autologous blood or blood components is another option. Autologous blood involves collecting the patient’s own blood or blood components before, during, and/or after a procedure. In one scenario a patient may donate his own blood or components, usually several weeks prior to an elective procedure. This blood is stored in the blood bank until the patient’s surgery. This is called preoperative autologous blood donation (PABD). PABD is not an option for Jehovah’s Witnesses as the blood completely leaves the circulatory system and is stored. During a surgical procedure, healthcare professionals can use cell-salvaging equipment to collect and then transfuse the blood that a patient loses (intraoperative blood salvage). Blood shed at an operative site is aspirated, washed, and returned to the patient. Although this equipment has limitations (for example, most physicians believe it to be contraindicated in bowel, cancer, or obstetrical surgeries), it can also give the surgical team a “cushion” in exceptionally bloody cases, such as trauma surgery. A similar procedure can collect and transfuse blood postoperatively as is often the case following joint replacement surgeries where postoperative blood loss can exceed intraoperative loss. Some of the risks associated with transfusing salvaged blood are coagulopathy, renal insufficiency, and air embolism.

Acute normovolemic hemodilution (ANH) allows facilities to offer bloodless surgery in cases once thought too bloody to justify the risk of an operation. ANH is intentional preoperative hemodilution induced by the isovolemic exchange of whole blood with colloid or crystalloid solutions to preserve autologous blood, while maintaining normovolemia. In other words, a portion of the patient’s blood is removed and replaced with acellular fluid, resulting in the loss of “watered-down” blood during the surgical procedure and storage of rich whole blood at the patient’s side awaiting reinfusion during or after surgery. Because this procedure can be carried out in a manner that maintains an unbroken connection with the patient’s circulatory system, it is acceptable to many who decline blood for religious reasons. This too poses some risk for the patient, such as organ ischemia from the reduced oxygen carrying capacity that occurs from the loss of red blood cells.

Aggressive and Prompt Treatment: One of the elementary principles of bloodless care is to stop any bleeding as soon as possible. This means not “observing” a gastrointestinal bleed, but intervening surgically (when indicated) as soon as possible. Smaller windows of opportunity exist for patients who will not accept a blood transfusion, so surgeons must act quickly and be meticulous in hemostasis. Equipment, such as an argon-beam coagulator that helps provide a drier operating field by cauterizing as it cuts, can help reduce intraoperative blood loss. The use of intraoperative or postoperative salvage and reinfusion can make a critical difference in an anemic patient.

Anesthesiologists also have techniques that can contribute to positive outcomes for patients who don’t want to be transfused with blood. One of these is hypotensive anesthesia. With hypotensive anesthesia, blood pressure is lowered during portions of the surgery that are anticipated to be bloody so that less blood will be shed.

Minimally Invasive and Noninvasive Procedures: Although not appropriate for every case, alternatives to traditional, invasive procedures can decrease blood loss. For example, stereotactic radiosurgery is a noninvasive approach to surgery where high-density radiation is delivered directly to a tumor while surrounding tissue receives minimal radiation. The high dose effectively treats the tumor, while the focused beam minimizes damage to surrounding tissue. Minimally invasive coronary artery bypass surgery is performed by operating on a beating heart. This eliminates the complications, like hemolysis, that can be caused by placing a patient on a heart-lung bypass machine and can contribute to postoperative anemia.

Maximizing a Patient’s Own Blood Supply: Pharmacologic technology has provided the field of bloodless medicine and surgery with some valuable tools in the form of hematopoietic agents — medications that stimulate the body to produce various blood cells.

Recombinant erythropoietin (rEPO) is a synthetic form of a natural human hormone that stimulates red blood cell production.⁷ It is manufactured using recombinant DNA technology and has the same pharmacological effects as endogenous human erythropoietin. The drug can be administered before, during, or after medical or surgical treatment to stimulate red blood cell production. It can also be used to accelerate hematopoietic recovery in cancer patients who undergo chemotherapy or to treat anemia in patients with chronic renal failure. Iron and other hematinics (agents that improve the blood quality) are administered concurrently to support erythropoietin-stimulated red blood cell production. rEPO is the most commonly used hematopoietic drug. The drug’s generic name is epoetin alfa (Procrit).

Other medications stimulate white blood cell and platelet production. Recombinant granulocyte-colony stimulating factor is a biosynthetic form of a natural human hormone that stimulates production of neutrophils, a specific type of infection-fighting white blood cell, in the bone marrow.⁷ It is also manufactured using recombinant DNA technology and has the same biological effects as endogenous human granulocyte-colony stimulating factor. Recombinant interleukin-11 (IL-11) is a genetically produced form of a naturally occurring human hormone that stimulates the body’s platelet production.⁷ Interleukin is important in managing patients who receive drug therapy, such as chemotherapy, that tends to suppress the development of platelets. Several medications are also available to treat patients in the event of hemorrhage. Aprotinin (Trasylol) is a naturally occurring agent isolated from bovine lung tissue that reduces bleeding during and after surgery. Aprotinin can be used along with heparin in the management of disseminated intravascular coagulation.⁸ Another agent helpful for treating hemorrhage is desmopressin (DDAVP, Stimate), which causes constriction of bleeding vessels to limit blood loss. Desmopressin is also used before invasive procedures for patients with impaired clotting.⁸ A newer hemostatic agent is recombinant human coagulation factor VII. In addition to these, other topical hemostatic agents and tissue sealants/adhesives exist.

Pipeline therapies: Blood substitutes are being engineered and perfected. Two main types of blood substitutes exist; hemoglobin-based oxygen carriers (made from either expired donated human blood, recombinant human hemoglobin, transgenic pig hemoglobin, or bovine hemoglobin) and perfluorocarbons. Several companies in the U.S. are currently conducting various stages of clinical trials on these oxygen-carrying fluids, but none are approved for use at this time.

Legal issues

As early as the 1960s, many physicians and facilities began to explore alternatives to blood transfusions. The Patient Self-Determination Act (PSDA) of 1990 gave these efforts more impetus. The PSDA was the first federal law to ensure that patients were informed of their right to accept or refuse medical care.⁹ Facilities that want to receive reimbursement through Medicare and Medicaid must comply with it.

The PSDA empowers patients to choose or decline any medical treatment. Healthcare professionals have an obligation to ensure that patients make informed choices, and they are required to abide by patients’ choices. The PSDA allows patients with religious beliefs forbidding blood transfusions to maintain their convictions, even when they are not able to speak for themselves — for example, when a patient’s family does not agree with his or her choice of religion. Family members may feel frustrated with a loved one who makes healthcare choices they do not agree with or understand. Conversely, decisions left to a family to make in a time of crisis can be difficult. However, adherence to the PSDA ensures a win-win situation. Families are spared anguishing over choices, and patients get only the treatments they desire.

All adult patients, regardless of age or medical condition, should be encouraged to complete an advance directive. They should be strongly advised to do so if they have serious convictions regarding certain aspects of medical treatment.

The issue of bloodless surgery and medicine is much more complicated regarding children. Minors, unlike adults, cannot choose to refuse treatment. Conflict can arise when parents have a religious conviction that will not allow them to consent to a blood transfusion. In the past, the solution of choice was a court order. Against parents’ wishes, courts relieved them of the task of making medical decisions, and blood was transfused. However, the creation of organized bloodless or transfusion-free programs has made the relationship between parents and healthcare providers less adversarial. Bloodless programs that make provisions for minors usually have parents sign an agreement that clearly states at least some of the following: (1) state law as it pertains to refusal of life-saving treatment for a minor; (2) under what circumstances a physician will be compelled to transfuse a minor (for example, when loss of life, limb, or major organ is imminent, and a blood transfusion is the only way to reasonably prevent these consequences); (3) the requirement that healthcare providers explore and exhaust treatment modalities available to avoid a blood transfusion to respect the wishes of the parent; and (4) ) the provision that the parent or parents are not consenting to blood or relinquishing their parental rights. Once these issues are clarified, the parent-provider relationship can be one of collaboration. A child can only benefit when an agreeable relationship exists between parents and healthcare providers.

Scientific support for bloodless treatment

A search of current medical literature will yield hundreds of articles that support restrictive transfusion practice. The results of several prospective clinical studies indicate that a restrictive transfusion regimen is associated with lower morbidity and mortality than a liberal transfusion policy. In general, it is well documented that while there is certainly a place for blood therapy in health care, blood transfusions can be associated with poor outcomes.

The scope of bloodless care

Resources are now available to patients regardless of why they may decide to avoid blood transfusions. With concerns about the adequacy of the blood supply in the U.S., the number of bloodless centers is sure to grow. Currently, more than 100 centers are open in the U.S. Both national and international associations for transfusion-free or bloodless health care have been formed, such as the Society for the Advancement of Blood Management (SABM); and the Network for Advancement of Transfusion Alternatives, which present international conferences annually. Many providers now believe that care without the use of blood is good practice. They are limiting blood transfusions whenever possible, regardless of the patient’s personal or religious convictions. So the next time a patient is scheduled for a surgical procedure and is asked to sign a consent for blood “just in case,” think about whether a blood transfusion will really be necessary, and what can be done to avoid it.