American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Statement on Recommendations for Surgeons Caring for Patients Who Are Jehovah’s Witnesses

The American College of Surgeons (ACS) Committee on Ethics developed a Statement on Recommendations for Surgeons Caring for Patients Who Are Jehovah’s Witnesses. The Board of Regents approved this statement at its June 2018 meeting in Chicago, IL.

Surgeons highly value and respect patient autonomy and simultaneously desire to provide high-quality, effective treatment. Furthermore, surgeons do not want to contribute to the death of a patient, particularly a patient whose death might be prevented by transfusing blood. To provide optimal care for patients who are Jehovah’s Witnesses (JWs), surgeons should aim to respect and accommodate each patient’s values and target the best outcome possible given the patient’s desires and his/her clinical condition.

It is not possible to provide blanket guidelines or standards for the care of JW patients. To attempt to give recommendations about when and what to transfuse (blood, plasma, cell saver), how to respond in an emergency, and so on, could have serious unintended consequences. Each person who is a Jehovah’s Witness is unique and will have personal ideas about what is and what is not acceptable for them to take into their body. Because these desires are not applicable to JW patients as a group, the unintended consequences of an overly prescriptive document or blanket recommendations could harm individual patients.

Instead, the ACS proposes the following best practices to consider in the approach to care of the JW patient.

  1. Treat each patient individually. It is critical to sit down with patients who are Jehovah’s Witnesses and very clearly review what they will and will not permit their surgeon to transfuse and when. Most JWs will not permit cell saver or red blood cell transfusion. Some will take albumin, but very few will take fresh frozen plasma. Almost all JWs will take an organ. The goal is not to decide what people should believe and whether those beliefs are consistent, but rather to respect the patient’s views and beliefs and treat the individual in accordance with those beliefs.
  2. Use community resources. Many JW patients have already thought through their own beliefs regarding transfusions and carry a document that very clearly outlines their preferences. Often JWs will present for treatment with family members or other representatives of their faith who can help them navigate the health care system and ensure their desires are respected.
  3. Be sure the patient is free from coercion. All patients have a right to privacy and should be asked in a private setting about preferences, beliefs, and values. At times, patients will express the beliefs of those around them, which may differ from their own preferences, and these patients will need support from physicians to express their own beliefs and understanding of the consequences of their refusal to accept transfusion in a private setting.
  4. Assess stability of patient preferences. Whereas some JW patients may very clearly state preferences to avoid transfusion in an elective, nonemergent, nonlife-threatening situation, some may change their mind if their condition becomes life-threatening. People have the right to change their mind. The surgeon’s responsibility is to make sure without being antagonistic that the preference to refuse transfusion is stable and would not change if the patient’s condition were to become life-threatening. For example, the surgeon could say, “I understand that your goals and values are to not take blood, and now that it is getting to the point where your anemia is critically threatening to your life, I want to confirm that these are still the goals and values that you hold. I want to be sure that you understand that the consequences of not having a blood transfusion could very well be death.”
  5. Remember JW patients’ desire to refuse treatment is just about transfusions. JW beliefs should not be confused with other belief systems that are anti-Western medicine or anti-technical interventions. JWs are, as a group, healthier than the general population because of lifestyle choices. They tend to be compliant with other medical treatments and, as such, are often willing to pursue many other types of interventions. They should not be deprived of necessary care based on the false assumption that refusing blood transfusions means that they do not want to consider other medical interventions.
  6. Transfuse in the emergency setting when preferences are unknown or unclear. In the emergency setting, patients often do not have the capacity to make their own decisions. Sometimes patients are unconscious, or sometimes the surgeon does not have time to evaluate the patient’s capacity as this process would delay emergency treatment and lead to the patient’s death. In the emergency setting, therefore, surgeons are on solid ground in treating JW patients with a transfusion under the standard of presumed consent. Some patients will have very clear advance directives about not accepting blood. To the degree the surgeon can be certain that the advance directive applies to the specific patient in the specific setting, then it is acceptable to follow that directive.
  7. Accommodate some preferences but not others in children. For unemancipated patients under the age of 18, family members (and patients) cannot generally refuse life-saving treatment for a minor-aged patient. It is not acceptable to let a child die from severe anemia because of their parents’ or guardians’ religious beliefs. Certain patients younger than the age of 18 may be deemed emancipated under state laws and, thus, are empowered to make their own medical decisions and should be treated as adults for purposes of transfusion decisions.
    1. Designation of decision-making capacity at a certain age is an arbitrary but necessary legal distinction. While age 18 is the age of majority in most states, in certain states the law is different, or different with regard to medical decision making; thus, the surgeon should understand the laws in the state where he or she practices. In the emergency setting, when the child’s life is at risk, it is acceptable to transfuse an unemancipated patient who is younger than 18 years old over the objections of parents or the patient. In a nonemergency setting, surgeons should obtain a court-appointed guardian for permission for transfusion. In cases where a transfusion is deemed medically necessary for a minor patient, and the child’s life is in danger, courts will typically intervene over the religious objections of the parents.
    2. When the patient’s condition is not life-threatening, there may be room for accommodation. In settings where other children may receive a transfusion, for a JW child, surgeons can permit anemia that may have some harm, but is not so harmful as to cause the death of the child.
    3. Consider leeway to respect patient/parent preferences. Should surgeons take parents to court or employ a guardianship to get permission for a blood transfusion in settings when it is very unlikely to be needed? For example, a child with appendicitis: The parents and child who are JW consent for appendectomy but will not consent for blood transfusion during appendectomy if, for some unforeseen reason, it were necessary. Given the chances of needing blood during an appendectomy are extraordinarily rare, particularly in a child, a demand from the surgeon to consent for a blood transfusion would be burdensome to both the patient and the family. Thus, it would be reasonable, in this setting, to proceed to the operating room with consent for appendectomy without getting consent for blood. In the extremely rare occurrence of needing blood during appendectomy, blood could be provided based on the emergency recommendations described previously. Note that surgeons can disclose in advance that they will transfuse in the event of life-threatening hemorrhage, which supports the integrity of this relationship without requiring parental consent to transfusion or court intervention. Consideration of this type of leeway regarding consent to transfuse is not advised in settings where transfusion is very likely to be needed (for example, complex cardiac procedures, large tumor resections).
    4. Decisions to accommodate anemia and leeway should be up to the individual surgeon, as some surgeons might have an emotional response to restrictions on their capacity to provide lifesaving care or might worry that inaction violates their professional integrity. Surgeons should carefully consider the burdens of demanding consent for transfusion when it is unlikely to be needed, and work to support the patient’s and family’s right to self-determination.
  8. Remember, “bloodless surgery” is good surgery. Fortunately, general practices about blood transfusion and blood conservation have evolved over time and are consistent with the needs of many JW patients. All patients have better outcomes when surgeons lose less blood and when patients receive fewer transfusions. Although JW patients often seek out institutions that have bloodless surgery, all surgeons and institutions should aim to practice bloodless surgery.

Some institutions serve a large population of JW patients and have developed important programs and resources to address the specific needs of JW patients. These institutions not only practice bloodless surgery, but they often have the infrastructure to support these patients, including social workers and religious advisors, and they have generated a trusting relationship between the institution and local JW community, which has real benefits for JW patients.

Reprinted from Bulletin of the American College of Surgeons
Vol. 103, No. 9, September 2018