Perioperative blood management in Jehovah’s Witnesses

BACKGROUND: Jehova's Witnesses refuse the administration of allogenic blood products for religious reasons. This stance represents a special challenge for the perioperative management and requires individualized ethically sensitive and medically founded strategies. In this respect patient blood management (PBM) provides a structured and evidence-based approach for optimization of the preoperative, intraoperative and postoperative care. OBJECTIVE: Description of the current medical, ethical and legal procedure for the management of patients who refuse blood transfusions exemplified by Jehova's Witnesses and presentation of a standardized clarification model. MATERIAL AND METHODS: Narrative overview of current recommendations and guidelines on preoperative treatment of anemia, intraoperative coagulation treatment, autotransfusion and the legal framework of action. In addition, a questionnaire on differentiated clarification developed at the University of Bonn is presented. RESULTS: A timely structured management of anemia, the application of viscoelastic point of care diagnostics and the differentiated use of autologous procedures, such as mechanical autotransfusion, enable a safe perioperative treatment even in cases of refusal of allogenic blood transfusion. Legal aspects underline the binding to patient advance directives, particularly in adults able to provide informed consent. For children, the child's welfare is prioritized in emergency cases. The clarification form presented reduces uncertainties and strengthens the interdisciplinary decision making. CONCLUSION: An individualized PBM concept represents an effective and ethically tenable strategy for the perioperative treatment of patients who refuse blood transfusions. It combines medical safety with respecting patient autonomy.