Patients who profess the faith of Jehovah’s Witness have always presented a vexing problem for hospitals when they’ve required surgery. Because their religion prohibits them from taking blood, they believe they must always decline transfusions, even if their refusal results in their death., but a report on Jehovah’s Witness members who underwent seven types of cardiac surgery at the Cleveland Clinic indicates that with pre-operative blood conservation strategies, the patients did not have more complications than patients who were not Jehovah’s Witnesses and did receive transfusions.
“What we showed is that by comparing a group of Jehovah’s Witness patients to a group of patients who were transfused, the Jehovah’s Witness group seemed to do no worse, and under certain criteria actually did better, than patients who were transfused,” says Gregory Pattakos, MD, one of the researchers. The article was published Monday in the Archives of Internal Medicine.
The study suggests that blood transfusions in and of themselves carry under-recognized risks that offset risks from refusing blood transfusions, says Pattakos, who now is a general surgery resident at Georgetown University Hospital in Washington, D.C.
He cautions that the results should not be overinterpreted, because the topic requires much more research for validation. He emphasizes, however, that surgeons should give the idea of transfusion a lot more thought for each patient, rather than acting with “a knee-jerk reaction when a particular (hemoglobin or hematocrit) level is reached.”
For Jehovah’s Witness patients undergoing cardiac surgery, common strategies include initiating doses of the drug erythropoietin and iron and B-complex vitamins, hemoconcentation and minimal crystalloid use, intraoperative use of antifibrinolytics and cell saver and smaller cardiopulmonary bypass circuits, and postoperative liberal use of additional operations for bleeding, the researchers wrote. Additionally, surgeons operating on Jehovah’s Witness patients agree to tolerate a steeper drop of hematocrit levels postoperatively.
“Although some of these practices may be beneficial to all cardiac surgical patients, others are associated with well-documented morbidity, and their effect on long-term survival is uncertain,” the authors wrote. Nevertheless, when the Witness patients and the non-Witness patients who received transfusions were compared, they had similar risks of in-hospital mortality, stroke, atrial fibrillation and renal failure.
However, Witnesses had lower occurrence of postoperative myocardial infarction, prolonged ventilation, and additional operation for bleeding; they also had shorter intensive care unit and postoperative lengths of stay. Pattakos and his fellow researchers say they don’t know why the Jehovah’s Witness patients fared as well or even better than their patient counterparts who received transfusions. It may be that erythropoietin and other blood-conserving strategies—believed to carry their own risks of higher morbidity such as stroke—were really less dangerous than receiving donated blood.
“There is a growing trend and increased awareness now of the negative side effects of blood transfusions that in prior decades was not realized,” Pattakos says. “It would be interesting to study whether the majority of cardiac surgery patients would benefit from erythropoietin (before surgery) because we do not know that yet,” he adds. Pattakos emphasizes that a major flaw in the study is that the Jehovah’s Witness patients did not all receive the same blood conservation strategies prior to and during surgery, so it is hard to tell whether some pre-operative efforts worked better than others.