Jehovah

1
Jehovahs Witnesses Medical and Legal Issues

• Dr Emer Lawlor
• Hospital Liaison Committee Workshop
• 7th November 2007

2
Legal and Ethical Background
3
The Liberty Principle- Autonomy 1

• the only part of the conduct of anyone ,for
  which he is accountable to society,is that which
  concerns others. In the part that merely concerns
  himself/herself,their independence is,of
  right,absolute.Over himself,over his body and
  mind, the individual is sovereign.
• JS Mill 1859 On Liberty

4
Liberty Principle-Autonomy 2

• The only purpose for which power can rightfully
  be exercised over any member of a civilized
  community against his will is to prevent harm to
  others.
• His own good neither physical or moral is not a
  sufficient warrant. He cannot rightfully be
  compelled to do or to forbear because it will be
  better for him to do so ,because it will make him
  happier,because in the opinions of others, to do
  so would be wise or even right.
• JS Mill On Liberty 1859

5
Consent

• Every human being of adult years and sound
  mind has a right to determine what shall be done
  with his own body and a surgeon who performs an
  operation without his patients consent commits
  an assault for which he is liable in damages
• Cardozo J
• Schloendorff v Society of New York Hospital
  (1914)
• Art 40.3 Irish Constitution 1937 Rights to self
  determination, bodily integrity and privacy

6
Elements of Consent

• Patient has the capacity (age, mental status)
  to understand and decide
• Voluntary (no undue influence)
• Informed -knowledge of risks and alternatives

7
History Of Jehovahs Witnesses

• Religious community founded in Pennsylvania 1870
• 30,000 in Germany in 1933 -Only group to stand up
  to the Nazis -33 imprisoned ,1,200 killed to
  April 1945
• Prohibition of Blood Transfusion dates from 1July
  1945
• Up to 15th June 2000 consequences for JW
  accepting BT were disfellowship and shunning
• Post 2000 ,JW recipient of BT dissociates
  himself/ herself
• Currently 6,000,000 JW worldwide numbers rising
  in Africa and South America
• Sacks DA, Koppes JD 1986 Blood transfusion and
  Jehovahs witnesses Mdical and legal issues in
  obtetrics and gynaecology Am JOG 154 483-486
• Johnston EA 1999 Nazi Terror the Gestapo,
  Jews, and Ordinary Germans Basic Books
• Muramoto 0( 2001) Bioethical aspects of the
  recent changes to the policy of refusal of blood
  by Jehovahs witnesses BMJ 322 37-39

8
Legal and Ethical Position

• To administer blood to a mentally competent adult
  patient who has steadfastly refused it, having
  been fully advised of the medical consequences,
  is unlawful and ethically unacceptable.

9
Informed consent in Jehovahs Witness cases

• Capacity-age,mental status
• ? reduced capacity drugs/condition
• Voluntary- undue influence relatives,religious
  advisors
• Knowledge of risks/alternatives have the risks
  of no transfusion been explained?
• Is refusal intended to apply in the particular
  circumstances ?

10
In re T ( Adult Refusal of Treatment) 1993

• 20 year old daughter of JW ( not herself JW) RTA
  pregnant refused transfusion.
• ? reduced capacity- pneumonia,pethidine
• ?undue influence from mother
• Caesarian section ,stillborn infant,ventilated
• risks of no transfusion not explained
• not intended to apply in the particular
  circumstances

11
JM v The Board of Management of Vincents
Hospital 2003 1IR

• Liver transplantation
• Woman who had converted to JW following marriage
  some months before
• Initially when lucid had discussed with husband
  who had left decision to her
• Subsequently when weaker and not so clear in mind
  first accepted transfusion but 10 mins later
  refused to sign consent
• Court felt that decision was not clear and final
  as more concerned about husbands religious
  beliefs than own welfare
• Made Ward of Court and transfused

12
Medical Aspects
13
Jehovahs Witnesses

• Accept all modern medical treatment apart from
  transfusion of components
• Will not accept autologous transfusion but will
  usually accept cell salvage or acute normovolemic
  haemodilution if not detached from body
• Fractions such as immunoglobulins,albumin etc up
  to individual conscience
• Recombinant products accepted

14
What are the risks of death without blood
transfusion ?

• Review of 1404 cases involving major surgery
  between 1977 -1990 -Primary cause in 8 patients
  (0.6) Contributory in 20 deaths (1.4)
• Kitchens CS 1993 Amer J Med 94 117-119
• 2083 adults refusing blood at surgery between
  1981-1994
• 201 patients with Hb lt 7g/dl with lowest
  post op Hb 8.0g or less -overall mortality 24
• Carson JL et al 2002 Transfusion 42 812-818
  
• ICU patients between 1999 Sept 2003 21 JW
  cases 4 deaths (19) versus 782 in 8848 (8.8)
  p0.10
• MacLaren G ,Anderson M Anaesth Intensive
  Care 2004 32 798-803

15
Jehovahs Witnesses

• All other measures to reduce blood loss should be
  taken eg surgical, rVIIa, EPO
• Hospital should have a policy for JW
• Identify doctors prepared to treat JW
• Contact numbers of out of hours legal
  representatives
• Refusal form should explain to patient in simple
  terms bigger print/bold/different colour the
  consequences of refusal

16
Elective
17
Elective procedures

• Meeting with patient ahead of time with surgeon
  and anaesthetist (and Haematologist) to discuss
  management
• Treat any treatable anemia
• Discuss acceptable options
• Review up to date Advance Directive/ JW no blood
  card -
• Discuss hospital refusal form
• Code of Practice for The Surgical Management of
  Jehovahs Witnesses (2002). The Royal College of
  Surgeons of England

18
Emergency
19
Emergency Management of JW Adults

• Ensure policy in place to manage if consent or
  refusal unknown or unclear
• 2 consultants detailed note confirming need and
  reasons for transfusion
• Contact hospital legal team
• Application to court
• In emergency where consent unclear transfuse
  before application
• Royal College of Surgeons of England 2002 Code
  of practice for the Surgical Management of
  Jehovahs Witnesses /Association of Anaesthetists

20
Children
21
Jehovahs Witnesses Children 1

• Child under 16 Emergency Care Order to District
  Court under Sec 12 Child Care Act 1991 or to High
  Court to be made Ward of Court
• In emergency transfuse as failure could lead to
  criminal charges( In re T 1992)
• Documentation by 2 consultants of reason and need
  for transfusion
• Important to involve the parents

22
JW Children 2

• Child over 16 can consent to treatment (Sec 23
  NOPA 1997)and does not need parental consent
• What about refusal? If parent consents no case
  law but probably parental consent would overrule
• If both refuse -urgent legal advice but manage as
  under 16

23
Re L ( A minor)

• L 14 yo girl with epilepsy who was a Jehovahs
  Witness
• Fell into hot bath with hot tap still running 54
  of body burned 40 third degree burns
• Had signed No Blood Card
• Child psychiatrist -strongly held views based on
  family experience-contrasted with opinion based
  on adult experience
• Court ordered transfusion in Ls best interests
• Fam Division The President June 10 Medical
  Litigation August 1998 p8-9

24
Useful Guidelines

• References
• Code of Practice for The Surgical Management of
  Jehovahs Witnesses (2002). The Royal College of
  Surgeons of England
• Management of Anaesthesia for Jehovahs Witnesses
  (1999). The Association of Anaesthetists of Great
  Britain and Ireland.
• Management of Anaesthesia for Jehovahs Witnesses
  (2nd Edition 2005). The Association of
  Anaesthetists of Great Britain and Ireland.

25
Management of Patients refusing Blood Transfusion
26
Severe Iron Deficiency

• 26 year old woman
• Iron deficient during pregnancy
• Post Partum Hb 6.5 g/dL
• Septic
• Refusing blood

Ref Dr. Jane KeidanBBTS Presentation Sept 2007
27
Plan

• IV iron 200mgs TIW for 3 doses
• Recheck Hb after 3 days
• Hb 5.2, no reticulocyte response
• One dose erythropoeitin (40IU Eprex)
• Hb 9.8 one week later

Ref Dr. Jane KeidanBBTS Presentation Sept 2007
28
Management of Massive Post partum Haemorrhage
29
Case Study 2

• 37 yr Jehovahs Witness 5th pregnancy
• Previous PPH x 3!
• Delivered at 39 weeks
• Massive bleed
• Hb dropped to 4.5
• Ref Dr. Jane Keidan

30
Plan

• Return to theatre for surgical assessment and
  control of bleeding
• Electively ventilate on ITU
• Check and recheck Advance Directive.
• Give 200mg Venofer T/W
• Give 3x doses of erythropoeitin (40K Eprex)
• Hb dropped to 2.4 g/dl
• Hb 5.6 g/dl one week post delivery

Ref Dr. Jane Keidan BBTS Presentation Sept 2007
31
What did we learn?

• Alert consultant obstetrician and anaesthetist,
  plus Hospital Transfusion Team(HTT) at booking if
  refusing blood.
• HTT to make a plan and communicate clearly and
  widely
• If PPH occurs call in the consultant obstetrician
  even if minor to start with.
• ITU ask for advice early if bleeding.
• Advance directives are VERY useful especially in
  an emotionally charged situation, but must be up
  to date.

Ref Dr. Jane Keidan BBTS Presentation Sept 2007
32
Role of VIIa ?
33
Guidelines for off license use of rFVIIa in
acquired coagulopathy

• Use of rFVIIa should be considered in
• Ongoing significant haemorrhage despite
  appropriate attempt at surgical control and
  correction of other deficiencies
• Severe obstetric haemorrhage continuing despite
  optimal blood product replacement and obstetric
  measures, where uterine artery ligation/embolisati
  on or hysterectomy are under consideration
• Severe haemorrhage refractory to local control in
  patients who refuse components.Administration in
  these patients may need to be earlier in the
  course of events because tranfusion is prohibited

Modified from Regional Guidelines
Northern Ireland Advisory Committee on Blood
Safety August 2007 and
34
NovoSeven Mode of action Eptacog alfa (activated)
The thrombin burst leads to the formation of a
stable clot
35
Proposed protocol for use of rFVIIa in obstetric
haemorrhage

• 90 µg/kg dose
• Use must be authorised by Consultant
  Haematologist and Consultant Obstetric
  Anaesthetist
• ? A single dose should be kept in delivery suite
  to facilitate rapid administration in appropriate
  circumstances not current practice
• rFVIIa use should not be seen as an alternative
  to surgical haemostasis or correction of
  coagulopathy with blood products.

ref Dr. John HanleyBBTS Presentation Sept 2007
36
Conclusions

• Due to changing ethnic population, the challenge
  of managing bleeding in JW patients will
  increase
• Policies need to be in place to manage needs of
  JW patients in all hospitals
• The Hospital Transfusion Department
  haemovigilance officers, blood transfusion
  medical scientists and haematologists have a
  vital role to play and should be involved as
  early as possible.