Author(s): <p>Danielle Brazel* and Jeffrey A Wong</p>
Introduction: The refusal of blood products by Jehovah’s Witnesses (JW) is one of the most frequent cases of refusal of medical treatment. Blood consents enable patients to express their preferences but critically ill patients often do not have the capacity to make these decisions. The general practice is for JWs to carry a specific wallet-sized advanced directive (AD) blood refusal card on their person which lists specific fractionated blood products that are, or are not, acceptable to them. We review the medical, ethical, and legal considerations for transfusing these patients and also discuss some of the challenges in treating a patient without the blood AD for both emergent and routine transfusions that may save his or her life.
Case Presentation: An unconscious 60-year-old COVID-19 positive patient was transferred from an outside hospital. On hospital day 30, his hemoglobin dropped to 6.9. Although he previously identified as a JW and indicated no blood transfusions in a note from 15 years ago, he is now intubated and sedated. There was also no blood AD, nor was the medicine team able to contact his family in rural Mexico for confirmation. He required a total of three blood transfusions over his hospital course before he died.
Discussion: In a JW patient without capacity and a blood refusal AD, blood transfusion to preserve life is justified. Case law has conflicting decisions but most recently affirmed that the physician should default to the preservation and prolongation of life. Ultimately, the physician has the responsibility to prove the patient’s informed refusal when withholding life-saving treatment. However, if an AD blood refusal or documented history of blood transfusion refusal, then the physician should respect the autonomy and religious values of the patient to decline treatment. Although the 15-year-old documentation is not as ideal as an AD, the JW AD should be respected to the same degree as non-JW AD and Provider Orders for Life Sustaining Treatment (POLST) Finally, the clinical team also has a duty to inform patients who identify as JWs of any blood transfusions that were administered over the hospital course.
