jehovah s witnesses: medical and legal issues

1. Jehovah’s Witnesses: Medical and Legal Issues Dr Emer Lawlor Hospital Liaison Committee Workshop 7th November 2007

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 patient’s 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 Jehovah’s 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 Jehovah’s 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 Jehovah’s 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 Jehovah’s 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 Vincent’s 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 husband’s religious beliefs than own welfare Made Ward of Court and transfused

12. Medical Aspects

13. Jehovah’s 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 < 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%) p=0.10 MacLaren G ,Anderson M Anaesth Intensive Care 2004 32 798-803

15. Jehovah’s 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 Jehovah’s 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 Jehovah’s Witnesses /Association of Anaesthetists

20. Children

21. Jehovah’s 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 Jehovah’s 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 L’s 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 Jehovah’s Witnesses (2002). The Royal College of Surgeons of England Management of Anaesthesia for Jehovah’s Witnesses (1999). The Association of Anaesthetists of Great Britain and Ireland. Management of Anaesthesia for Jehovah’s 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

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

28. Management of Massive Post partum Haemorrhage

29. Case Study 2 37 yr Jehovah’s 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

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.

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/embolisation 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

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.

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.