A person who is bleeding refuses surgery

Acquiescence, not consent. Approving palliation. Compulsory treatment for diabetes. Vulnerable with capacity. Informed consent and informed dissent: two sides of a coin? Patients value candour. Best interests in the absence of suffering. Going to court too soon. Compulsory treatment in grave circumstances. Communicating risk: words or numbers? Feasibility of covert caesarean. Justifying termination of pregnancy. Reasons for refusing blood. Determining incapacity. Deceiving patients.

Preaching to patients. Is there a role for next of kin? Can patients rely on their advance decisions? Children refusing treatment. Seeking the court's approval for genetic testing. Body modification. Separating conjoined twins. Aspects of disclosure. Mixed messages. Encourage patients not to leave untreated.

But all life is an experiment. A right to be told? Nasogastric tubes: a narrow dispute. Falling from hospital property. Disclosing the minuscule risk for consent. Distinguishing mental disorder from mental incapacity: a brief guide.

Gross negligence manslaughter: what does 'gross' entail. Material risks. Consent for surgery. References Petrini C Ethical and legal aspects of refusal of blood transfusions by Jehovah's Witnesses, with particular reference to Italy. Blood Transfus 12 Suppl 1: ss Garraud O Jehovah's Witnesses and blood transfusion refusal: what next?

Woolley S Jehovah's Witnesses in the emergency department: what are their rights? Emerg Med J JAMA Best Pract Res Clin Anaesthesiol A review of medicosurgical attitudes in a University hospital in Ann Fr Anesth Reanim The treatment of Jehovah's Witness patients.

Soc Sci Med Vincent JL Transfusion in the exsanguinating Jehovah's Witness patient--the attitude of intensive-care doctors. Eur J Anaesthesiol 8: Indian J Anaesth Harrington C Father shunned by family for defying faith to save child. Canadian Press. BMC Med Ethics Vasc Health Risk Manag 4: Transfus Med Rev Br J Anaesth Hematol Rep 4: Crit Care Clin Transfusion Alter Transfusion Med J Intensive Care Med Degoute CS Controlled hypotension: a guide to drug choice.

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Religious objections to medical carexs. American Academy of Pediatrics Committee on Bioethics. Practice guidelines for perioperative blood transfusion and adjuvant therapies: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. The use of erythropoietin in the management of Jehovah's Witnesses who have revision total hip arthroplasty.

J Bone Joint Surg Am. Clinical strategies in the medical care of Jehovah's Witnesses. Am J Med. Crit Care Med. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. Shander A, Goodnough LT. Why an alternative to blood transfusion? Crit Care Clin.

Human cardiovascular and metabolic response to acute, severe isovolemic anemia. Preoperative resuscitation of the trauma patient. Curr Opin Anaesthesiol. Experimental analysis of critical oxygen delivery. Goodnough LT, Shander A. Blood management. Arch Pathol Lab Med. Macdougall IC. Intravenous administration of iron in epoetin-treated haemodialysis patients - which drugs, which regimen?

Nephrol Dial Transplant. Berend K, Levi M. Management of adult Jehovah's Witness patients with acute bleeding. Anaphylactoid reactions to vitamin K. J Thromb Thrombolysis. Hsieh A, Cheong I. Am J Emerg Med. Welsh AM. Richard Riley. Australasian Anaesthesia. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions.

Methods A total of Witnesses and 87 non-Witnesses underwent cardiac surgery at our center from January 1, , to January 1, All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 did not receive blood transfusions and 48 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival.

Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival. Results Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.

Conclusions Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status.

Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival. Red blood cells RBCs not only are in short supply but are also associated with increased morbidity and reduced survival after cardiac surgery.

Their beliefs encourage the use of a number of blood conservation practices, including preoperative use of erythropoietin and iron and B-complex vitamins, hemoconcentration, and minimal crystalloid use; intraoperative use of antifibrinolytics and cell-saver and smaller cardiopulmonary bypass circuits; and postoperative liberal use of additional operation for bleeding along with tolerance of low hematocrit levels postoperatively.

Although some of these practices may be beneficial to all cardiac surgical patients, others are associated with well-documented morbidity, 4 - 6 and their effect on long-term survival is uncertain.

Although prior investigators compared immediate postoperative outcomes between Witnesses and non-Witnesses, 7 - 16 comparisons of long-term survival are lacking. Comparison is hampered, however, by impossibility of randomization to religious preference or blood transfusion, typical of any natural experiment.

We have therefore used propensity-based comparative effectiveness tools 17 - 19 to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a propensity-matched group of patients who received transfusions.

A total of 96 adult patients underwent cardiac surgery at Cleveland Clinic from January 1, , to January 1, In addition, non-Witnesses and 5 Witnesses with missing information about blood transfusions were excluded.

Only the first operation during the study period was considered, which eliminated operations. After exclusions, we identified 87 consecutive cardiac surgery patients, among whom were Witnesses and 87 were non-Witnesses. Among the non-Witnesses, 48 Thus, the trial cohort consisted of Witnesses and 48 non-Witnesses who received transfusions Figure 1 and eAppendix 1.

We obtained blood transfusion data along with clinical data and outcomes from the Cardiovascular Information Registry CVIR , a prospective database updated concurrently with patient care. The CVIR receives electronic laboratory and echocardiographic data, but most of its more than variables per patient are abstracted by a team of full-time nurses trained in cardiothoracic surgery or medicine. These data form the basis for national reporting, local quality initiatives, and research. The Cleveland Clinic institutional review board approved use of these data for research, with individual patient consent waived.

Baseline and perioperative factors for non-Witnesses and Witnesses are listed in eAppendix 2. We considered in-hospital complications acute complications for which the Society of Thoracic Surgeons has provided benchmarks, including return to the operating room for bleeding, stroke, atrial fibrillation, myocardial infarction, renal failure, respiratory insufficiency, sepsis, and in-hospital death.

We determined time-related all-cause mortality by querying the Social Security Death Master File using a closing date of February 6, , and by querying follow-up data collected systematically from the CVIR.

Only 1 patient a Witness was lost to follow-up. Witnesses had patient-years of follow-up mean [SD] follow-up, 9. Non-Witnesses who received transfusions had patient-years of follow-up mean [SD] follow-up, 8.

Because neither religious preference nor receipt of blood transfusion among non-Witnesses could be randomized, we expected to find differences in the distribution of preoperative and operative characteristics of Witnesses and non-Witnesses.

Using logistic regression analysis, in which being a Witness was the dependent variable, we constructed a model of the probability of being a Witness as opposed to a non-Witness with non-Witnesses who received transfusions, considering all preoperative and selected operative variables listed in eAppendix 3.

During the study, new variables were introduced in , , and Therefore, 4 bootstrap models were run: one with variables available for all years using all data, another with variables available for all years plus those available after using only those patients operated on after , another with variables available for all years plus those available after using only those patients operated on after , and, finally, one with variables available for all years plus those available after using only those patients operated on after We synthesized information from these 4 bootstrap models to create a single parsimonious model.

Variables missing during an extended period were treated as interactions with time and thus set to zero for that period. Next, we augmented the parsimonious model with the most reliable predictors from clinically relevant groups to form propensity models see eAppendix 3 for variables included in each propensity model.

We assessed association of Witness status with long-term mortality using a wholly parametric multiphase hazard method. The method enabled us to assess nonproportional hazards, a feature common to interventional procedures that carry transiently high early risk that subsides to considerably lower levels after a variable duration of recovery. Unadjusted hospital outcomes were compared using the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables, and comparisons between Witnesses and propensity-matched non-Witnesses who received transfusions adjusted comparison were performed using the paired McNemar test for categorical variables and paired t test for continuous variables.

All analyses were performed using SAS statistical software, version 9. All P values are 2-sided, with a value of. Categorical variables are summarized by frequencies and percentages and continuous variables by means and standard deviations or 15th, 50th, and 85th percentiles when values are skewed. Comparison of outcomes of propensity-matched pairs used the McNemar test for binary variables and paired t test for continuous variables.