1. The Jehovah’s Witness Flashcards
Intro
Jehovah’s Witnesses (JW) date back to the 1870s and consider themselves a part of the Christian religion.
Their text is the ‘The New World Translation’ of the Bible; they believe that Jesus, the only son of Jehovah, died for our sins, but they do not accept the concept of the Holy Trinity.
They maintain political neutrality, believing that only
God, not government, should be in the ultimate position of authority, and consequently remain as conscientious objectors during conflict.
There are, of course, many facets to the religion beyond the scope of this book, but the
one that causes us considerable concern as doctors is the refusal of some JWs to accept the transfusion of blood products.
This refusal is results from the words in Genesis 9:3–4, Leviticus 17:11–12, and Acts 15:28–29.
What are Jehovah’s Witnesses’ beliefs surrounding transfusion of blood products?
A committed JW is forbidden by the
scriptures-from receiving blood products.
Transgressing this rule compromises their relationship with God and may leave a JW feeling that life is meaningless.
Giving blood products to a JW against their will has been likened, by them, to the assault of rape,
in terms of its psychological impact.
Each competent adult has the right to refuse to give consent to any treatment and does not have to explain their reasons for this refusal. If a doctor wilfully transfuses a JW against their wishes, then he/she is liable to criminal and civil prosecution for assault, and
also could be subject to GMC disciplinary proceedings.
Which products are unacceptable?
Unfortunately, there are no hard and fast rules, as each individual will decide which treatments are acceptable to them. Generally, the following are not acceptable:
> Whole blood > Packed cells > White cells > Platelets > Fresh frozen plasma > Autotransfusion of blood that has been taken and stored
The individual will decide about the acceptability of the following:
> Blood salvage
> Dialysis
> Haemodilution
> Cardio-pulmonary bypass (non-blood-primed circuit)
> Blood fractions, e.g. albumin, immunoglobulins, clotting factors
> Transplanted organs
> Epidural blood patches
It is important to discuss beliefs with the individual before planning the anaesthetic, blood loss prevention and rescue strategies.
Patients can discuss the various blood products and strategies with a committee of elders called the ‘Hospital Liaison Committee for Jehovah
Witnesses’.
Each hospital switchboard will have this number.
It is important to document clearly all discussions with the patient.
There is a special consent form for JWs, upon which their specific individual wishes must be recorded.
How would you assess a Jehovah’s Witness pre-operatively for elective surgery?
> A JW included on a list should be flagged up
as soon as possible so that their wishes can be discussed and the best anaesthetic/surgical
technique planned.
> A consultant who is happy to anaesthetise JWs should be allocated to the case.
> Clearly, the risk to the individual will be related to the nature of the surgery.
It is sensible to discuss the risks with the patient alone,
so that they are under no duress from other members of the church when it comes to making decisions about their treatment.
> The decisions made following this consultation must be entered in the notes, dated, timed and signed by both the doctor and the patient.
The discussion must be frank and honest,
and the consequences of refusing blood or blood products impressed upon the patient.
> Any anaemia should be investigated and
treated in a timely manner, where possible.
Oral iron may be given (this will not raise Hb acutely),
or for some, recombinant erythropoietin is acceptable (though it is not licensed for this use).
Discuss cases that are not straightforward with a
haematologist.
How would you assess a Jehovah’s Witness
pre-operatively for emergency surgery?
> The principles of patient care are unchanged here,
but there may be uncertainty as to the patient’s wishes if they have lost ‘capacity’ by the time of presentation.
> Many JWs have an advanced directive
detailing their wishes.
If they are not carrying this,
it is often lodged with their GP and
efforts should be made to find it.
> If no advanced directive exists, or can be found, for a patient lacking capacity, we must act in the perceived best interests of the patient.
This can mean giving blood/blood products
if we believe the therapy to be
truly life saving.
The decision-making process must be documented
meticulously,
and a consultant must be involved in the decision.
Describe how you would conduct your anaesthetic for a
Jehovah’s Witness.
The surgical and anaesthetic techniques must be aimed at minimising blood loss.
The following options should be considered where appropriate:
> Arterial tourniquets
> C reful positioning
> Hypotensive anaesthesia
> Vasoconstrictors
> Haemodilution
> Meticulous haemostasis
> Optimising clotting –
avoid acidosis and maintain normothermia
> C ell salvage,
if this is acceptable to the individual and not contraindicated by their condition
> Drugs that promote clotting, e.g. Factor VIIa, tranexamic acid and aprotinin.
It may be sensible to stagger operations
to allow for haematological
recovery in between each one.
Several operations lend themselves
to regional techniques,
e.g. caesarean delivery.
This can help to reduce blood loss
and also, should bleeding
become life threatening,
the awake patient may have the opportunity to
change their mind about receiving blood/blood products.
Are there any special considerations for the
post-operative period?
> Monitor ongoing blood loss –
surgical re-exploration
must not be delayed
if bleeding is suspected.
> Patients who have suffered
excessive blood loss may need to be
electively ventilated in an attempt to optimise their oxygen delivery.
> There are reports of using
hyperbaric oxygen therapy in the face of very
low haemoglobins,
but this is not widely available.
Issues surrounding capacity and consent.
We include this section because
these issues are of interest and not well
covered in other texts.
However, examiners will not expect you to be masters
of law.
To display an appreciation of the sensitive nature
and potential complexity of the issues,
and to show appropriate caution and seek senior
advice, will be enough to pass.
Children <16 years of age:
By law, this group may give consent to treatment
if they are believed to function at a level that allows them to
understand the information given them,
weigh it in the balance,
use it to make a decision
and communicate that
decision.
This is called being ‘Gillick-competent’, so called because of the legal case brought by Victoria Gillick which turned on the issue of whether a minor may have the capacity to give valid consent.
The court believed that they might and consequently, a ‘Gillick-competent’ child may, in theory,
consent to, or refuse, treatment.
However, in practical terms, at the time
of publication, the courts have never upheld a child’s refusal of life-saving treatment, no matter how well reasoned their argument.
Applying past case law to the situation
in which a child who is a Jehovah’s Witness needs a
life-saving blood transfusion, it is most likely that the courts will find that the child does not have the capacity to refuse this treatment.
Conversely, if a child who is deemed Gillick-competent consents to a blood transfusion,
that consent stands even in the face of parental refusal.
If both the parents and the child refuse transfusion, or the child is not Gillick competent
to give consent in the face of parental refusal, the medical team can apply for a ‘Special Issue Order’ via the High Court.
If granted, this
will allow the doctors to give treatment.
This order must only be sought in
non-emergency situations where
it is thought that the treatment will prevent
serious permanent harm or be life saving.
The manager on call for the
hospital will have the procedural
information for obtaining a
‘Special Issue Order’.
In a life-threatening emergency, the child should be treated with whatever
means necessary to preserve life, regardless of the parents’ wishes.
Children 16–18 years of age:
According to the Mental Capacity Act 2005, patients of 16 years and over
can be assumed to have the capacity to make decisions regarding their
treatment; however, the parents, rather paradoxically, retain the right to
consent for a child until they reach 18 years. This could lead to potential
conflict if a patient aged 16–18 years were a JW but their parents were not.
Here, a situation could arise in which the child refuses blood/blood products
but the parents want them to be transfused. In this case, the law would
suggest that the patient is treated as an adult and their choice to refuse
respected, provided the patient understands the consequences of their
decision. This situation has not yet been tested in the courts and therefore
no precedent has been set. Looking to the law for guidance, there is no
‘correct answer’ to this dilemma. Whatever the decision, there are going
to be serious repercussions – either the patient’s wishes are ignored and
medical therapy commenced or the parents’ wishes are ignored and they
are left bereaved. If time permitted it would be sensible to seek legal advice
on such issues. All decisions must be made at consultant level. All treatment
must be given in the best interests of the patient.
The rights of the anaesthetist.
Anaesthetists have the right to refuse to undertake elective anaesthesia
on JWs, but are duty-bound to refer such cases to someone with the
appropriate expertise, who is willing to be involved.
In emergency situations, anaesthetists are expected to provide care to JWs,
and fully abide by their wishes, once these have been verified.
