There are 8.5 million Jehovah’s Witnesses worldwide, meaning that encountering a Jehovah’s Witness in the medical workplace is not uncommon. The combination of the potential for major haemorrhage and the limitation of blood product administration makes the pregnant Jehovah’s Witness a challenge for the anaesthetist. Observational study suggests that the pregnant Jehovah’s Witness has a greatly increased risk of morbidity and death.
Problems and special considerations
Understanding the motivation and conviction behind blood product refusal is important when providing care to a Jehovah’s Witness. This primarily stems from a literal interpretation of the Bible, for example:
For the life of every creature is its blood: its blood is its life. There fore I have said to the people of Israel, You shall not eat the blood of any creature, for the life of every creature is its blood. Whoever eats it shall be cut off. Leviticus 17:14
This has been interpreted by Jehovah’s Witnesses to mean that the acceptance of blood products will result in the loss of their faith and place in their community; the alternative option is preferable to many.
Secondly, Jehovah’s Witness information sources cite the medical benefits of refusal of blood products such as avoiding exposure to blood-borne diseases, immune-system reactions and human errors; alternatives such as bloodless surgery and blood conservation techniques are recommended. While the benefits of avoiding blood transfusion are clearly supported by an evidence base, depending on the clinical context, this is often not transferable to the acute major haemorrhage that may be seen in obstetrics.
Management options
The pregnant Jehovah’s Witness should be seen in both obstetric and anaesthetic antenatal clinics. This gives the opportunity for optimisation and planning before delivery. Anaemia must be treated; if oral iron is inadequate, intravenous iron should be offered. Supplemental folate and vitamin C can be added. Erythropoietin maybe offered to those refractory to iron, and may be acceptable.
The antenatal review also gives the opportunity to explore which blood products or synthetic products (if any) are acceptable, and which techniques, such as cell salvage, may be used (Table 152.1). There may be significant variation between what different Jehovah’s Witnesses find acceptable; the individual patient’s wishes should be clearly documented, and she must be reassured as to the confidentiality of her decision. If the woman has an advance directive, a copy should be prominently displayed in her notes. A frank discussion regarding the individual’s risk of haemorrhagic complications of pregnancy and labour, and the potential consequences (including death), should occur to ensure that decisions are informed, and this discussion should be recorded in the clinical notes. It must be made clear that there are currently no blood substitutes with the ability to carry oxygen that are licensed for use in the UK, a misunderstanding that is sometimes encountered. Most hospitals and trusts will have a pro forma for patients who might refuse blood and related products.
Table 152.1 Usual range of acceptability to Jehovah’s Witnesses of blood and blood-related products (note that individual patients may have very specific views, and these must be sought and documented in each case)
|
Usually acceptable |
Sometimes acceptable |
Usually not acceptable |
|
Iron, folate |
Albumin |
Whole blood |
|
Tranexamic acid |
Clotting factors |
Packed red cells |
|
Desmopressin |
Immunoglobulins Cryoprecipitate Recombinant erythropoietin Prothrombin complex concentrate Factor VIIa concentrate Cell salvage Cardiopulmonary bypass Haemofiltration |
White cells Platelets Plasma |
Jehovah’s Witnesses may be subject to coercion by family members or others (e.g. religious leaders), such that they may state their refusal of blood products if others are present, but agree to certain treatments when the options are discussed in private. Staff must be aware of this risk and be certain that the views recorded reflect those of the woman herself, free of coercion.
Of those who will accept cell salvage, some may request a continuous circuit to be used, such that there is no ‘break’ in the continuity of blood leaving and entering the body. This has also been requested when performing epidural blood patches, the mechanics of which have been detailed in case reports.
Senior experienced clinicians should lead care in the peripartum period. During delivery, prompt use of uterotonics is recommended. Mechanical techniques to control haemorrhage, including hysterectomy, may be considered sooner than in non-Jehovah’s Witnesses in the event of major haemorrhage. This should have been discussed during the antenatal visits.
Alternative intraoperative techniques to counter blood loss and its effects, such as permissive hypotension and normovolaemic haemodilution, need careful consideration in the obstetric setting. Case reports have described the use of peripartum hyperbaric oxygen therapy in the critically anaemic Jehovah’s Witness, to maximise oxygen delivery.
In emergency clinical situations, where the patient does not have the capacity to make informed decisions, advice should be sought from the hospital legal team. In general, the patient’s views must be respected, even if this results in her death. However, if there is any doubt as to the mother’s wish not to receive blood products under any circumstances (e.g. if this is not clearly documented in the notes or in a signed advance directive), then the default position would be to preserve life.
Key points
• Advance communication and preparation and multidisciplinary team work are essential when caring for the pregnant Jehovah’s Witness.
• The views of Jehovah’s Witnesses vary regarding receipt of blood and blood-related products, and these must be sought and clearly documented for each individual patient, including all circumstances in which such treatments would or would not be acceptable.
• The risk of coercion by family members and others must be considered, and the true wishes of each patient ascertained.
• Certain treatments (e.g. cell salvage and epidural blood patch) may be acceptable if a continuous circuit of blood is maintained.
Further reading
Jehovah’s Witnesses. Official website. www.jw.org/en (accessed December 2018).
Lawson T, Ralph C. Perioperative Jehovah’s Witnesses: a review. Br J Anaesth 2015; 115: 676-87.
Mason CL, Tran CK. Caring for the Jehovah’s Witness parturient. Anesth Analg 2015; 121: 1564-9.