Surgical management in treatment of Jehovah's witness in trauma surgery in Indian subcontinent

Anesthesia Approach to Managing Severe Hemorrhagic Shock and Anemia With Non-transfusion Alternatives in a Practicing Jehovah's Witness: A Case Report

Traumatic hemorrhagic shock is a common yet life-threatening occurrence across the United States and is typically managed with blood transfusions as the standard of care. However, providers caring for a Jehovah's Witness patient who refuses transfusions due to religious reasons face unique ethical challenges in upholding evidence-based shock resuscitation protocols while respecting the patient's autonomy and faith-based stance that strictly prohibits blood products. We present a complex clinical case of a 46-year-old Jehovah's Witness who developed severe hemorrhagic shock, partial amputation, and critical anemia after a traumatic 40-mile-per-hour motorcycle collision resulting in comminuted fractures and arterial disruption. Despite receiving emergent blood transfusions initially, further transfusions were declined once his identity as a practicing Jehovah's Witness was disclosed. His hemoglobin plunged to dangerously low levels of 4.6 g/dL before stabilizing to 5.3 g/dL with pharmaceutical alternatives including intravenous iron, high-dose erythropoietin, and phlebotomy minimization. Respecting patient convictions while delivering effective evidence-based shock management created significant ethical conflicts given the proven efficacy of blood transfusions. However, this complex case demonstrates that through meticulous medical and surgical care coordinated by a multi-disciplinary team applying customized non-transfusion techniques, traumatic hemorrhagic shock and life-threatening anemia can still achieve favorable outcomes without relying on transfusions when respecting faith-based refusal of blood products.

Major abdominal surgery for Jehovah's Witnesses: Challenge while practicing bloodless medicine in a middle income country

We present a 59-year-old female Jehovah's Witness patient transferred from another facility to our tertiary center as an emergency case owing to anemia due to gastrointestinal bleeding. A computed tomography scan and gastroscopy confirmed an invasion of the duodenum by a malignant process. The patient underwent a Whipple procedure and a right hemicolectomy refusing blood transfusion. On the 17th postoperative day, the patient was discharged following a successful surgery. This article's objectives are to first highlight the moral and ethical quandary and then share our surgical experiences with this particular patient population. In conclusion, Jehovah's Witnesses' management of major abdominal surgery poses considerable clinical, moral, and legal difficulties. Despite them, doctors must put the patients' needs first while also honoring their religious convictions. However, urgent situations continue to arise, forcing medical professionals to weigh their religious convictions against the need to save a patient's life.

Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report

BACKGROUND Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah's Witness. On day 4, the patient's hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.

Tranexamic Acid for the Treatment of Acute Gastrointestinal Bleeding in a Jehovah's Witness Patient on Apixaban and Dual Antiplatelet Therapy: A Case Report

Life-threatening bleeding can be challenging to manage, especially in patients who reject allogeneic transfusions for religious or personal reasons. Tranexamic acid (TXA) has been successfully used to treat acute bleeding in multiple settings with varying severity, including trauma, women with postpartum hemorrhage, hemoptysis, and epistaxis, with minimal adverse effects. The purpose of this case report is to describe the use of TXA to aid in achieving hemostasis in a Jehovah's Witness patient on apixaban with a life-threatening gastrointestinal (GI) bleed. An 80-year-old female Jehovah's Witness patient on apixaban for lower extremity deep vein thrombosis presented to the emergency department with 8 hr of GI bleeding. On presentation, she was hemodynamically unstable, requiring a norepinephrine infusion. She refused any blood-derived products or anticoagulant reversal agents derived from human or animal products. One 1-g dose of intravenous TXA was given as a bolus for more than 10 min, followed by another 1-g dose for more than 8 hr. The patient achieved successful hemostasis allowing for further inpatient management and eventually was discharged from the hospital. This case describes a life-threatening GI bleed in a Jehovah's Witness patient who was successfully treated using TXA.

Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

Trauma e transfusão sanguínea precoce: o desafiante manejo de hemorragias em Testemunhas de Jeová

RESUMO O manejo de pacientes que se recusam a receber transfusões de sangue e de seus produtos, como as Testemunhas de Jeová, apresenta-se frequentemente como desafio médico, não só pelo dilema ético, mas porque cria um importante obstáculo ao rápido controle de hemorragias num cenário de trauma. Este artigo explora as razões deste conflito entre o dever de cuidado do médico e o respeito à autonomia do paciente, e desenha um panorama dos entendimentos majoritários do Judiciário sobre o tema. Por fim, conclui-se que a manifestação de vontade do paciente, embora livre, não é suficiente para afastar o médico do seu dever de cuidado. Constatando perigo à vida, o médico deverá proceder a transfusão de sangue, independentemente de consentimento do paciente ou de seus responsáveis.