Advances in general and vascular surgical care of Jehovah's Witnesses

Background: Jehovah's Witnesses are an enlarging religious community in the US and throughout the world. Members of this faith refuse administration of blood during medical or surgical therapy even if death may occur as a consequence. The surgeon is consequently faced with difficulties and moral dilemmas of caring for these patients. Patients and Methods: From July 1, 1975 to March 1, 1999, the author performed 132 general and vascular surgical procedures on pediatric and adult patients who were Jehovah's Witnesses. Results: A surgical series of 132 patients who are Jehovah's Witnesses is reported. The series includes general surgical procedures in children and adults. Also, vascular surgical procedures in adults are reported. Thirty-one procedures were of significant magnitude to possibly require a blood transfusion. No patient in this series received a blood transfusion. No patient was refused an indicated surgical procedure. Fourteen complications incurred in this series which included one death. The age range of patients in this surgical series was 9 months to 91 years. There was no difference in the male to female ratio. The spectrum of cases reported represents the entire range of procedures seen in general and vascular surgical practices. Conclusions: The surgical care of Jehovah's Witnesses has become less of an operative risk over the last decade. There are now significant alternatives to the transfusion of blood, such as erythropoietin, iron dextran, aprotinin and Fluosol-DA 20%. Technological surgical developments and advances, such as the cell saver, argon beam coagulator, acute limited normovolemic hemodilution, autologous whole plasma fibrin gel, and controlled hypotensive anesthesia during anesthesia have contributed substantially to a reduction in the operative loss of blood. The time honored rule of hemoglobin of 10 g/dl and a hematocrit of 30% should not require strict adherence in the postoperative care of most patients. The acceptance of a lower transfusion trigger point of hematocrit of 22% and a hemoglobin of 7 g/dl can significantly reduce transfusion requirements without an increase in morbidity. Ethical considerations are discussed and evaluated when treatment restrictions, such as blood transfusion and other life-preserving therapies are limited by religious beliefs or living wills.