Jehovah’s Witness Patients

Consider advocating controlled hypotension more strongly than in patients who will accept blood products. Take particular care not to order laboratory tests which require phlebotomy but which will not change management.

It is difficult to make broad recommendations on the treatment of Jehovah’s Witness patients, as most (but not all) case series are relatively small, and prospective studies comparing different management strategies do not exist. It is even more difficult to extrapolate data from JW patients to the population as a whole, because even if certain levels of hemoglobin are predictive of mortality, it does not necessarily follow that intervention would be effective.

Carson et al. have published three studies on the subject – in the first, a case-control study of 125 patients who declined blood transfusions, operative mortality was inversely related to preoperative haemoglobin level (7.1% if Hgb > 10 g/dl, 61.5% if < 6 g/dl) and proportionately related to blood loss (8% for < 500 ml, 42.9% for > 2000 ml). No patient with Hgb > 8 g/dl and operative blood loss < 500 ml died [Carson JL et al. Lancet 1: 727, 1988]. In the second, a retrospective cohort of 1958 adult patients who declined blood transfusion found a 1.3% mortality for Hgb > 12 g/gL, as compared to 33.3% if < 6 g/dL, and this increased risk was particularly pronounced in patients with cardiovascular disease. The effect of blood loss was larger in patients with preoperative anemia [Carson JL et al. Lancet 348: 1055, 1996]. In the third, Spence et al. examined 113 elective operations on Jehovah’s Witness patients and found that while 93 had a preoperative Hgb > 10.0 (mortality rate 3.2%), the mortality rate for the 20 with Hgb < 10.0 was only 5%. Blood loss > 500 mL was predictive of mortality regardless of preoperative hemoglobin (no deaths in either group if EBL < 500 mL). [Spence et al. Am J Surg 159:320, 1990]

Lewis et al. examined a series of Jehovah’s Witness 663 who underwent cardiac surgery. The risk of death was significantly associated with repeat cardiac surgery, valvar dysfunction, LVEF < 0.35), and a POD1 hemoglobin < 8 g/dL. [Lewis CT et al. Ann Thorac Surg 51: 448, 1991]

Stamou et al. compared cardiac surgery outcomes in 49 Jehovah’s Witness patients to 196 non-Jehovah’s Witnesses. No significant differences were identified in unadjusted stroke, acute MI, new-onset A-fib (p = 0.106), prolonged ventilation (p = 0.82), ARF (p = 0.70), or hemorrhage-related reexploration (p = 0.59). On multivariate analysis, there was no significant difference in operative mortality, ICU stay, or postoperative length of stay. [Stamou SC et al. Am J Cardiol 98: 1223, 1996]

Viele et al., who searched MEDLINE for cases from 1970-1993, found 61 reports of untransfused Jehovah’s Witnesses with hemoglobin concentrations < 8 g/dL. Of 50 reported deaths, 23 were primarily due to anemia, and other than in cardiac surgery, all deaths due to anemia had a Hgb < 5 g/dL. That said, there were twenty-five documented survivors with hemoglobin < 5 g/dL. [Viele MK and Weiskopf RB. Transfusion 34: 396, 1994]

Tobian et al. performed a retrospective cohort study of 1958 Jehovah’s Witness patients that had surgery – 117 (5.6%) had a postoperative Hb level of 6 g/dL or less and 39 (33.3%) of these individuals died in the hospital. Post-operatively, the median number of days from surgery to the lowest Hb level was 3 days and from the lowest postoperative Hb level to death was 2 days. [Tobian AA et al. Transfusion 2009 {Epub ahead of print}]