10/6/07njm

**Q. How can we best manage Jehovah's Witnesses during pregnancy?**

A. The basics include use of anticipatory care and careful planning. See
details below

The basic princiiple in bloodless medicine is use of anticipatory care.
In postpartum hemorrhage, your facility should have a specific
pre-determined plan, as well as a postpartum hemorrhage kit in which the
salient instruments are readily available.

Bloodless medicine uses a two-pronged approach:

-Blood conservation

-Use of adjunctive therapy or blood substitutes

As an example, due to worries about uterine atony, some providers might
consider a cesarean delivery sooner in patients who have a poor \"labor
curve\" or a poor response to
[oxytocin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/190133&drug=true).
In addition, the threshold for performing a hysterectomy might be lower
in the presence of life-threatening postpartum hemorrhage.

Most of the world's literature is centered around events that
traditionally use large amounts of blood, e. g., open heart surgery. The
issues of OB/GYN hemorrhage, e. g., especially postpartum hemorrhage are
essentially the same as the other disciplines.

Skupski et al describes improving hospital systems for the care of women
with major obstetric hemorrhage. When 2 maternal deaths due to
hemorrhage occurred at New York Hospital Queens in 2000-2001, a
multidisciplinary team implemented systemic change. Their objective was
to improve outcomes of episodes of major obstetric hemorrhage.( Skupski
2006) Multiple other OB/GYN specific references are listed below.

**Background**

Jehovah's Witnesses believe that any blood removed from the body, even
their own, should not be given back. Autologous blood transfusions would
not be acceptable. (See brief review Jehovah's Witness's beliefs at the
bottom of this document\*)

Consenting to medical procedures where blood is taken out of the body
but reinfused continuously (ie, hemodialysis, heart-lung bypass machine,
and intraoperative cell saver) would be up to the individual.

Certain interventions (eg, surgery, induction of labor, use of
chemotherapy) may need to be performed sooner than expected due to the
absence of a \"buffer\" of being able to transfuse red blood cells. It
is important to discuss this with the patient.

As an example, due to worries about uterine atony, some obstetricians
might consider a cesarean section sooner in patients who have a poor
\"labor curve\" or a poor response to
[oxytocin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/190133&drug=true).
In addition, the threshold for performing a hysterectomy might be lower
in the presence of life-threatening postpartum hemorrhage. Patients at
risk should be advised of this possibility.

Jehovah's Witnesses, now about one million in the United States and
about six million worldwide, are interested in bloodless medicine or
medical care that would include alternatives to a blood transfusion.
With physicians willing to try another approach, medical progress has
been made in the field of transfusion medicine, principally blood
conservation.

Bloodless Medicine Medical Centers have been formed and are now present
in most major cities in the United States and in many cities around the
world. At a bloodless surgery program at the University of Rome, Italy,
a retrospective chart review of 51 JW patients showed low morbidity and
mortality rates for major as well as minor surgical procedures.
Incorporating bloodless medicine principles into a multidisciplinary
team approach is the overall goal.

To clearly inform their physician about the refusal of blood
transfusions, most Jehovah's Witnesses carry Durable Power of Attorney
cards that detail their wishes. These cards will also list minor blood
fractions and blood conservation technologies acceptable to them.
Respecting the religious conscience of the patient can be a challenge
but it is essential in treating the whole patient.

•Although Jehovah's Witnesses believe in "bloodless medicine," this does
not mean that they reject all medical practices.

•Bloodless Medicine Medical Centers have been formed and are now present
in most major cities in the United States and around the world.

•To clearly inform their physician about the refusal of blood
transfusions, most Jehovah's Witnesses carry Durable Power of Attorney
cards that detail their wishes. These cards also will list minor blood
fractions and blood conservation technologies acceptable to them.

**General Principles of Bloodless Medicine Management**

  -----------------------------------------------------------------------
  Employ a multidisciplinary treatment approach to blood conservation.

  Formulate a plan of care for avoiding/controlling blood losses.

  Consult promptly with senior specialist experienced in blood
  conservation.

  Promptly investigate and treat anemia.

  Decisive intervention, including surgery.

  Be prepared to modify routine practice when appropriate.

  Restrict blood drawing for laboratory tests.

  Decrease or avoid the use of anticoagulants and antiplatelet agents.

  Stimulate Erythropoiesis

  Transfer a stabilized patient, if necessary, to a major center before
  the patient's condition deteriorates.
  -----------------------------------------------------------------------

**Anesthetic and Surgical Blood Management Methods**

  -----------------------------------------------------------------------
  Rigorous hemostasis during surgery

  Surgical positioning of patient

  Tourniquets

  Hemostatic surgical devices

  Electrocautery

  Electrosurgery (diathermy)

  Ultrasonic scalpel

  Topical hemostatic agents and tissue adhesives and sealants

  Fibrin glue

  Tissue adhesives

  Autologous techniques

  Blood cell salvage devices

  Hemodilution

  Pharmacologic prophylaxis of bleeding

  Antifibrinolytics (tranexamic acid, anmioncaproic acid)

  Desmopressin

  RVIIa

  Fluid and volume management

  Colloids, Crystalloids
  -----------------------------------------------------------------------

**ALTERNATIVE COURSES OF ACTION**

Bloodless medicine encompasses many situations beyond those patients who
refuse transfusion. Examples include the wounded soldier on the
battlefield, a previously transfused patient with multiple
alloantibodies or an incompatible crossmatch for other reasons, and
surgical procedures performed in areas of limited blood supply.

Bloodless medicine uses a two-pronged approach:

-Blood conservation

-Use of adjunctive therapy or blood substitutes

Of critical importance for any patient unwilling or unable to receive
red cell transfusions is finding out, in advance whenever possible,
which of the available options for increasing the patient\'s
oxygen-carrying capacity is acceptable. These options include breathing
100 percent oxygen, hyperbaric [oxygen
therapy](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/59794&drug=true),
transfusion of the patient\'s own red cells either collected in advance
or recycled during surgery, and the use of alternative oxygen carriers,
[erythropoietin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/92788&drug=true),
and intravenous iron.

All of these issues require close and continuing consultation among
hematologists, intensivists, surgeons, anesthesiologists, transfusion
medicine specialists, and ethics committee members. The literature now
contains case reports of patients with complex medical and surgical
problems who have successfully completed therapy without resorting to
blood transfusion, e.g., placenta accreta (Weinstein 2005 below)

**Reducing blood loss** --- Blood conservation approaches are especially
applicable in the intensive care unit and the operating room. Multiple
studies have found mean daily phlebotomy losses in medical-surgical ICUs
of approximately 41 mL/day. Conservation practices have been
recommended, including decreased testing, small volume sampling, closed
sampling circuits, and point-of-care microtesting.

Other general practices include close attention to the degree of
anticoagulation (if employed), minimizing use of agents with
antiplatelet activity (eg,
[aspirin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/21595&drug=true),
nonsteroidal antiinflammatory agents,
[clopidogrel](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/2193&drug=true)),
and meticulous attention to hemostasis and technical blood losses during
surgery (eg, use of hemostatic surgical devices, fibrin glue and tissue
adhesives, controlled hypotension).

In bleeding patients, antifibrinolytic drugs decrease the need for
transfusion, although the safety of one of these agents,
[aprotinin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/20689&drug=true),
has been called into question.

Recombinant factor VIIa has been effectively used to reduce hemorrhage
and the need for transfusion in some Jehovah\'s Witness patients with
gastrointestinal or surgical bleeding. In one report of 27 consecutive
liver transplants in Jehovah\'s Witnesses, [recombinant human factor
VIIa](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/52919&drug=true)
as a single-dose infusion at the beginning of the operation was used in
13 patients to augment coagulation.

**Autologous transfusion** --- Devout Witnesses will not accept
transfusion of stored blood, including their own, due to a belief that
blood should not be taken out of the body and stored for any length of
time. However, if the blood circulates back into the patient (eg,
cardiopulmonary bypass, intraoperative and postoperative blood salvage
systems), this is acceptable to most Witnesses. Even for non-Witnesses,
the cost-effectiveness of autologous transfusion in the form of
preoperative ambulatory blood donation has been called into question.

Acute normovolemic hemodilution (ANH), in which the blood is in a
continuous circuit with the patient, may provide a workable alternative.
The use of
[erythropoietin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/92788&drug=true)
is sometimes required for this technique (along with iron, folate, and
[vitamin
B12](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/66951&drug=true))
to increase red cell mass in anticipation of surgery. While not always
cost-effective in patients for whom allogeneic transfusion is an option,
using erythropoietin in Jehovah\'s Witnesses to increase hematocrit and
allow ANH and/or other surgical procedures has been viewed as a prudent
measure.

[Erythropoietin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/92788&drug=true)
is acceptable to most Jehovah\'s witnesses. For patients with lower
hematocrits in whom ANH is a beneficial option, several weeks are
usually required to increase red cell mass. When surgery is planned, an
anesthesiologist comfortable with the procedure and with the patient\'s
transfusion restrictions should be involved in advance.

**Blood substitutes** --- A number of hemoglobin-based blood substitutes
are currently in development, with some in phase III trials, but none
has yet reached the market in the United States or Europe. Some of the
products have a history of successful use in Witnesses. The position of
the faith with respect to solutions containing human or animal
hemoglobin appears to leave the decision up to the individual.

**Oxygen supply and demand** --- When a patient cannot oxygenate vital
organs sufficiently, an alternative is to reduce the clinical need for
oxygen through sedation, mechanical ventilation with pharmacologic
paralysis, and meticulous control of body temperature. If the patient is
placed intermittently in a hyperbaric chamber, plasma itself may carry
sufficient dissolved oxygen.

**Resources**

[Remmers
PA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Remmers PA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Speer
AJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Speer AJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).Clinical
strategies in the medical care of Jehovah\'s Witnesses.\
Am J Med. 2006 Dec;119(12):1013-8. Review.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17145240>

**Approach to the patient who refuses blood transfusion, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=transfus/13269>

**Resources of interest in OB/GYN**

**Are women who are Jehovah\'s Witnesses at risk of maternal death?**

OBJECTIVE: The purpose of this study was to determine the rates of
obstetric hemorrhage and maternal mortality in women who are Jehovah\'s
Witnesses and to evaluate a protocol that uses erythropoietin to
optimize the red blood cell mass before delivery. STUDY DESIGN:
Obstetric outcomes were described for all of the women who were
Jehovah\'s Witnesses and who delivered at Mount Sinai Medical Center
during an 11-year period. The risk of maternal death was compared with
our general obstetric population during this interval. RESULTS: A total
of 332 women who were Jehovah\'s Witnesses had 391 deliveries. An
obstetric hemorrhage was experienced in 6% of this population. There
were 2 maternal deaths among the women who were Jehovah\'s Witnesses,
for a rate of 512 maternal deaths per 100,000 live births versus 12
maternal deaths per 100,000 live births (risk ratio, 44; 95% CI, 9-211).
Erythropoietin was associated with a nonsignificant increase in
hematocrit level. CONCLUSION: Women who are Jehovah\'s Witnesses are at
a 44-fold increased risk of maternal death, which is due to obstetric
hemorrhage. Patients should be counseled about this risk of death, and
obstetric hemorrhage should be aggressively treated, including a rapid
decision to proceed to hysterectomy when indicated.

[Singla
AK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Singla AK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Are women who are Jehovah\'s Witnesses at risk of maternal death?
[Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2001
Oct;185(4):893-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11641673>

 

**Recombinant human erythropoietin in a triplet pregnancy: a case
report.**

BACKGROUND: Women carrying triplets are at greater risk for both anemia,
due to the increased demands of the developingfetuses, and peripartum
hemorrhage. Jehovah\'s witnesses are a unique obstetric population since
women of this faith refuse blood transfusion. CASE: A Jehovah\'s Witness
with a triplet pregnancy was successfully administered recombinant human
erythropoietin (rHuEpo), 200 IU/kg 3 times per week subcutaneously, in
order to correct her peripartum anemia. No side effects were observed
during rHuEpo therapy, and the patient delivered healthy triplets.
CONCLUSION: rHuEpo can be safely administered, with a beneficial effect
in pregnancy, and seems to be an effective option in preventing
transfusions as demonstrated in this case in a Jehovah\'s Witness.

[Lialios
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lialios G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Recombinant human erythropoietin in a triplet pregnancy: a case
report. [J Reprod
Med.](javascript:AL_get(this, 'jour', 'J Reprod Med.');) 2005
Nov;50(11):863-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16419637>

**Obstetric care of Jehovah\'s Witnesses: a 14-year observational
study.**

Over a 14-year period, the obstetric outcome of Jehovah\'s Witnesses in
an inner city hospital was reviewed and the effect of refusal of blood
on morbidity and mortality evaluated. Ninety women had 116 deliveries
and of these, 24% were delivered by caesarean section, 10% had
instrumental deliveries and 66% were normal vaginal deliveries.
Postpartum haemorrhage of \>1,000 mls occurred in 6% and postpartum
anaemia was the commonest complication. The mean postdelivery
haemoglobin (11.10 +/- 1.15 g/dl) was not significantly less from the
mean predelivery haemoglobin level (11.81 +/- 1.62 g/dl) (P \> 0.05,
paired t test). The single maternal death occurred after caesarean
hysterectomy, which when extrapolated, resulted in a 65-fold increased
risk of maternal death compared to the national rate. The optimum
management of pregnant women who decline transfusion is discussed.

[Massiah
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Massiah N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Obstetric care of Jehovah\'s Witnesses: a 14-year observational
study. [Arch Gynecol
Obstet.](javascript:AL_get(this, 'jour', 'Arch Gynecol Obstet.');) 2007
Oct;276(4):339-43

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17522882>

**Bloodless surgery: establishment of a program for the special medical
needs of the Jehovah\'s witness community\--the gynecologic surgery
experience at a community hospital**

CONCLUSION: A program dedicated to the special needs of the Jehovah\'s
Witness community can be instituted in a community-based hospital with
no evidence of increased morbidity, as evidenced by length of stay,
hospital charges, and surgical blood loss, in a gynecologic patient
population. Development of such programs is associated with a high level
of patient satisfaction and the

[deCastro
RM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="deCastro RM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Bloodless surgery: establishment of a program for the special medical
needs of the Jehovah\'s witness community\--the gynecologic surgery
experience at a community hospital. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 1999
Jun;180(6 Pt 1):1491-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10368496>

**Major gynecologic and obstetric surgery in Jehovah\'s Witnesses**.

A retrospective study of 165 Jehovah\'s Witnesses and 164 Jehovah\'s
Witnesses and 164 control patients compared the morbidity and mortality
associated with major obstetric and gynecologic surgery in the 2 groups.
There were no deaths and few complications in either group. There were
few differences in preoperative and postoperative hemoglobin values.
Medicolegal implications of performing major surgery without blood
transfusions are discussed. The study adds evidence that major operative
procedures can be carried out on Jehovah\'s Witness patients without
blood transfusions or blood products.

[Bonakdar
MI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bonakdar MI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Major gynecologic and obstetric surgery in Jehovah\'s Witnesses.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
1982 Nov;60(5):587-90.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7145251>

**An audit of gynaecological procedures in Jehovah\'s Witnesses in an
inner city hospital**

A retrospective study of Jehovah Witness women between January 1994 and
December 2003 was performed. Gynaecologists are concerned about
operating on Jehovah\'s Witnesses because of the potential for
haemorrhage during surgery. Jehovah\'s Witnesses do not accept donor
blood but some will permit their own blood to be stored pre-operatively
and administered during surgery if deemed necessary. Approximately
150,000 Jehovah\'s Witnesses live in the UK but little on gynaecological
procedures in Jehovah\'s Witnesses has been published. There were 64
procedures (14 major, 18 intermediate and 32 minor) in 53 women with a
median age of 42 years. There were no perioperative deaths, but
postoperative anaemia was common. Our study showed that major,
intermediate and minor gynaecological procedures can be performed
without significant morbidity on Jehovah\'s Witnesses but a protocol
should be available to outline management of those who refuse blood.

[Massiah
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Massiah N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al An audit of gynaecological procedures in Jehovah\'s Witnesses in
an inner city hospital [J Obstet
Gynaecol.](javascript:AL_get(this, 'jour', 'J Obstet Gynaecol.');) 2006
Feb;26(2):149-51

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16483975>

**Blood transfusion and Jehovah\'s Witnesses: medical and legal issues
in obstetrics and gynecology.**

Jehovah\'s Witnesses are members of a religious denomination whose
beliefs prohibit the use of blood or blood products. Plasma volume
expanders and extracorporeal hemodilution of the patient\'s own blood
are theologically acceptable. Acute massive hemorrhage in which only
blood is lifesaving may be encountered in obstetrics and gynecology.
Either withholding or administering blood in such circumstances may have
legal consequences for the physician and hospital. Factors to be
considered include fetal viability, the presence of dependent children,
and rules of informed consent. Whenever possible, the potential for
transfusion should be anticipated and clearly discussed with the
patient. When appropriate, the physician and hospital should move
rapidly to obtain judicial resolution.

[Sacks
DA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sacks DA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Koppes
RH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Koppes RH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Blood transfusion and Jehovah\'s Witnesses: medical and legal issues in
obstetrics and gynecology. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 1986
Mar;154(3):483-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=3485378>

**Conservative management of placenta previa percreta in a Jehovah\'s
Witness**

CASE: We report a Jehovah\'s Witness patient who had 9 previous cesarean
deliveries and presented with anemia and placenta previa percreta
invading the bladder wall. Management objectives were to enhance the
patient\'s status, using erythropoietin and autologous transfusion, and
to minimize the chance of hemorrhage by prophylactic uterine artery
embolization. The placenta was left in situ after the delivery with no
untoward consequences. Methotrexate was held in readiness, but was not
required as adjuvant therapy. CONCLUSION: Effective care of such
patients requires close collaborative team effort and advanced planning
to ensure a good outcome.

Weinstein A et al Conservative management of placenta previa percreta in
a Jehovah\'s Witness.\
Obstet Gynecol. 2005 May;105(5 Pt 2):1247-50.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15863598>

**Improving hospital systems for the care of women with major obstetric
hemorrhage**

OBJECTIVE: When 2 maternal deaths due to hemorrhage occurred at New York
Hospital Queens in 2000-2001, a multidisciplinary team implemented
systemic change. Our objective was to improve outcomes of episodes of
major obstetric hemorrhage.

CONCLUSION: Despite a significant increase in major obstetric hemorrhage
cases, we found improved outcomes and fewer maternal deaths after
implementing systemic approaches to improve patient safety. Attention to
improving the hospital systems necessary for the care of women at risk
for major obstetric hemorrhage is important in the effort to decrease
maternal mortality from hemorrhage.

[Skupski
DW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Skupski DW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Improving hospital systems for the care of women with major
obstetric hemorrhage. Obstet Gynecol. 2006 May;107(5):977-83.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16648399>

**Postpartum Hemorrhage: New Management Options**.

ACOG Update Series Vol 32, No. 8 February 2007

**The Pregnant Jehovah\'s Witness: How Nurse Executives Can Assist Staff
in Providing Culturally Competent Care**

<http://www.nursingcenter.com/prodev/ce_article.asp?tid=618527>

**Making Your Pregnancy SAFER (Jehovah's Witness website)**

<http://www.watchtower.org/e/20030108/article_01.htm>

**\*PATIENT BELIEFS**

**Jehovah\'s Witnesses** --- While there are a number of situations in
which a patient may refuse blood transfusion, the most well-known
involve Christians known as Jehovah\'s Witnesses. With over one million
active members in North America and six million worldwide, Witnesses
embrace conservative family values and a pacifist attitude toward
firearms and violence. They are encouraged to purchase health insurance
and avail themselves of modern medical care, with the exception of
certain forms of blood transfusion. Aversion to transfusion stems from
their interpretation of Biblical scripture (eg, Genesis 9:3,4; Leviticus
7:26,27; 1 Samuel 14:32,33; and Acts 15:28,29).

-Practicing Witnesses generally will not accept transfusions of whole
blood or any of the \"four

major components\" (ie, red cells, platelets, plasma, and white blood
cells), and most are

prepared to die rather than compromise this refusal.

-Many Witnesses will accept blood subfractions, such as immunoglobulins,
albumin, coagulation

factor concentrates, and recombinant coagulation factors; the choice is
left up to individual

discretion and religious conscience. The degree of acceptability of
various products has been

summarized in the literature.

-Witnesses do not consider preoperative autologous blood donation as an
acceptable alternative,

due to a belief that blood should not be taken out of the body and
stored for any length of time.

However, if the blood circulates back into the patient (eg,
cardiopulmonary bypass, certain

intraoperative and postoperative blood salvage systems), this is
acceptable to most Witnesses.