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Password: Ethics
Case:

The patient is an 18-year-old Jehovah’s Witness with a history of severe and refractory lupus. She presents to the ED with a fever of 103.1 degrees, body aches, chest pain, and headache for 2-3 days. She is found to be in aplastic crisis with a hemoglobin 2.8 [normal 13.9-16.3], absolute neutrophil count (ANC) 430 [normal 1500-7800], platelet count 90,000 [normal 150,000-350,000]. Absolute reticulocyte count 0.004K/mm3 [normal 24.1-87.7]. Blood cultures are sent and she receives empiric antibiotics. She is short of breath with bilateral lower lobe infiltrates, so she is started on Non-invasive positive pressure ventilation (NiPPV) and escalating oxygen support. The JHH adult bloodless medicine team is consulted and recommends darbepoetin 300 mcg once weekly, erythropoietin 40,000 units IV daily, iron, vitamin B12, and folate supplementation. All of these therapies are initiated immediately.

The patient does not accept packed red blood cells, platelets, fresh frozen plasma (FFP), or white blood cells. She accepts the use of a cell saver. It is still being discussed with her and her church advisors whether she accepts what are considered minor fractionates from plasma (albumin, cryoprecipitate, immunoglobulins, clotting factors, platelet gel, and sealants). The erythropoietin that she is being given does not contain albumin.

In conversation with the medical team, the patient expresses understanding that her decision not to receive a packed red blood cell transfusion puts her at high risk of death. She states that if her heart were to stop beating that she would not want to receive chest compressions; therefore, her code status is updated as “No CPR.” She also expresses that she would want aggressive medical management up until her heart stops beating, including intubation and mechanical ventilation if deemed medically necessary.

Despite the aggressive treatments listed above, this patient’s hemoglobin continues to drop over the next several days, now 1.8. She remains alert but tired, hemodynamically stable, and on continuous NiPPV. As a last-ditch effort, the medical team offers intravenous immunoglobulin (IVIG) as a potentially beneficial treatment, specifically if the cause of her bone marrow suppression is viral. The patient shows interest in this therapy but asks for guidance from the bloodless medicine team prior to consenting. After discussion, trialing IVIG is agreed upon by the patient and medical team.

Due to the patient’s profound and refractory anemia, the ICU team no longer recommends intubation, as the medications and processes that go along with intubation will likely hasten death rather than help. The patient agrees with this recommendation and code status is changed to “No CPR- Do not intubate.” Later that evening, she gradually loses consciousness. NiPPV is stopped per her family’s understanding of her wishes. She dies peacefully minutes later with her family at her bedside.

In this case the patient’s wishes are well communicated. However, the care team expressed fear, anxiety, and feeling of helplessness as they strongly believed that the patient’s life could have been saved if she had received a blood transfusion. The case highlights the challenges that occur when the obligation to offer standardized medical interventions runs counter to respecting a patient’s faith and honoring her religious beliefs

Questions:

1. How does a faith community address a community member who chooses to receive a blood transfusion as a matter of conscience? Does the community member suffer any issues of stigma and alienation from the faith community?
2. Are there challenges in allowing adolescents and young adults brought up in a faith community to make their own decisions about their health care as a recognition of their burgeoning autonomy?
3. What are the ways that Jehovah Witness faith support the decisions of a young adult who makes an informed choice of not accepting blood transfusion during a life-threatening condition? Are there any ethical considerations for the faith community and moral responsibilities in caring for the young person?

Learning Objectives:

1. Describe the process for determining the ethically appropriate interventions based on patient’s faith beliefs.
2. Discuss the ways in which the Hopkins medical community could benefit from the input from Jehovah’s Witness faith leaders.
3. Discuss the Jehovah’s Witness perspectives on organ donation as well as transplant surgery for those who need organ transplant.

References:

1. Smith ML. Ethical perspectives on Jehovah’s Witnesses’ refusal of blood. Cleve Clin J Med. 1997;64(9):475-481. doi:10.3949/ccjm.64.9.475
2. Resar LM, Frank SM. Bloodless medicine: what to do when you can’t transfuse. Hematology Am Soc Hematol Educ Program. 2014 Dec 5;2014(1):553-8. PMID: 25696910.
3. Frank SM, Wick EC, Dezern AE, et al. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion. 2014; 54:2668-77. PMID: 24942198.
4. Resar LMS, Wick E. Almasri TN, Dackiw E, Ness P, Frank S. Bloodless medicine: current strategies and emerging treatment paradigms. Transfusion; 2016; 56:2637-47.
5. Chaturvedi S, Koo M, Dackiw L, Koo G, Frank SM, Resar LMS. Preoperative treatment of anemia and outcomes in surgical Jehovah’s Witness patients. Am J Hematol. 2019 Feb;94(2): E55-E58. Epub 2018 Dec 18. PubMed PMID: 30474135.