The patient who refuses blood
Stem
A 66-year-old man, 82 kg, a Jehovah's Witness, is scheduled in five weeks for revision of a loosened cemented total hip arthroplasty; the surgeon expects 1–1.5 L of blood loss. His hemoglobin is 11.2 g/dL with a ferritin of 18 ng/mL. He has capacity, carries a signed advance directive refusing blood, and has well-controlled hypertension.
Question
How will you prepare for and manage this operation?
Ideal answer
HeadlineI respect his refusal exactly, learn item by item what he accepts, and make this operation as bloodless as possible, starting with his hemoglobin.
- Privately, without family pressure, product by product: red cells, plasma and platelets he will refuse; cryoprecipitate, fibrinogen concentrate, prothrombin complex, albumin, cell salvage and acute normovolemic hemodilution are individual choices.1
- Every answer documented, including that he understands he could die, and the whole team told at the briefing, so nobody improvises.
- Intravenous iron, and hematology asked about erythropoietin, because he is iron-deficient with fewer than six weeks; I would delay surgery until his hemoglobin is optimized.1
- On the day: tranexamic acid, warmth, no hypertension, cell salvage in a continuous circuit if he accepts it, and hemodilution considered.2
- Small-volume tubes and close watch on blood loss, because what he loses cannot be replaced; we agree early when to stop.
Breaking down the answer
- Talk privately and specifically — the induction room is not the place for this conversation, and the decision is confidential; he can accept some treatments and refuse others without giving a reason.1 This is where the examiner grades ethics and communication.
- Accepted versus individual choice — whole blood is refused too; minor fractions, bypass and ECMO are individual choices; recombinant factors, erythropoietin and iron are acceptable because they are not blood-derived.1
- Optimize weeks ahead — check hemoglobin at least 6 weeks before major surgery and treat below 13 g/dL with iron and/or erythropoietin.1 Erythropoietin is commonly 400–600 units/kg weekly, hemoglobin rising no more than 1 g/dL per week.2
- Tranexamic acid — give it when blood loss over 500 mL is likely, and consider a further 1 g postoperatively for bleeding.1
- Cell salvage with caveats — most accept it when the blood stays in a circuit connected to him; it loses platelets and factors, and bone cement debris is a relative contraindication, which matters in a revision hip.2
- Hemodilution — fresh whole blood returned at the end carries platelets and factors, but needs a good starting hemoglobin.2
Follow-up question
Two hours in, he has lost 2 L, his hemoglobin is 5.4 g/dL, he is oozing from every surface, and the fibrinogen is low. His wife, in the waiting room, tells the surgeon to "do whatever it takes." What do you do?
Follow-up answer
HeadlineLife-threatening anemia with dilutional coagulopathy, and his documented refusal still binds us; his wife cannot override it.
I tell the surgeon to control bleeding and finish quickly, and I tell the room the plan. I give what he accepted: cell salvage, a further dose of tranexamic acid, and fibrinogen concentrate or prothrombin complex only if he agreed to fractions.1 I keep him warm and normocalcemic, avoid hemodilution with excess crystalloid, and support oxygen delivery with a high inspired oxygen fraction and a mean pressure of 65–75 mmHg.2 Many patients tolerate a hemoglobin of 5–6 g/dL.2 Afterward, sedation and ventilation if needed to reduce oxygen demand, erythropoietin and intravenous iron, and limited blood draws.
Pitfalls that cost points
- Assuming every Witness refuses the same things instead of asking item by item.
- Privately planning to transfuse "only if he would otherwise die"; that breaks the agreement.
Rapid-fire
Q: Which fractions are matters of individual choice? A: Cryoprecipitate, albumin, immunoglobulins and individual clotting factors.2
Q: Is preoperative autologous donation an option? A: Usually not; it is generally unacceptable, unlike hemodilution, which some accept.1
Q: What about a child of Witness parents? A: I act in the child's best interests and involve the hospital's legal team; in an urgent, life-threatening situation, blood is given to preserve the child's life.1
Q: Who can help with the conversation? A: The Witness Hospital Liaison Committee, available 24 hours a day, if the patient wants them involved.1
Q: Why choose an albumin-free erythropoietin product? A: Some epoetin alfa products contain albumin, which some patients decline.2
Numbers to know
| Item | Value |
|---|---|
| Check hemoglobin before major surgery | At least 6 weeks ahead1 |
| Treat preoperative anemia | Hb below 13 g/dL1 |
| Tranexamic acid | When loss over 500 mL is likely; 1 g postop if bleeding1 |
| Erythropoietin | 400–600 units/kg weekly; Hb rise ≤1 g/dL/week2 |
| Tolerated hemoglobin | Many tolerate 5–6 g/dL2 |
| MAP target | 65–75 mmHg2 |
Links
- Massive hemorrhage and transfusion, Treatment options and informed consent, Ethical issues: DNR, capacity, surrogates, refusal, Perioperative hypothermia and coagulopathy, dic
- Association of Anaesthetists guideline on Jehovah's Witnesses (2018); Guinn et al., Anesthesiology 2021
Sources
- 1.Anaesthesia and peri-operative care for Jehovah's Witnesses and patients who refuse blood · Association of Anaesthetists, 2018 · anaesthetists.orgUK guideline; legal sections (advance decisions, minors) reflect UK law.
- 2.Perioperative Management of Patients for Whom Transfusion Is Not an Option · Anesthesiology (Johns Hopkins Bloodless Medicine), 2021 · hopkinsmedicine.orgGuinn NR, Resar LMS, Frank SM. Anesthesiology 2021;134:939-48.
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.