Endgames

Preparing a Jehovah’s Witness for major elective surgery

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1588 (Published 14 March 2013) Cite this as: BMJ 2013;346:f1588
  1. Lillian Cooper, core surgical trainee 1,
  2. Kathryn Ford, core surgical trainee2,
  3. Elizabeth Miller, consultant haematologist3
  1. 1Royal London Hospital, London, UK
  2. 2King’s College Hospital, London SE5 9RS, UK
  3. 3Milton Keynes General Hospital, Milton Keynes, UK
  1. Correspondence to: kathryneford{at}gmail.com

A 75 year old woman who was scheduled to undergo elective right sided mastectomy and axillary node clearance was seen in the preoperative assessment clinic. She had been diagnosed as having a grade 3 invasive ductal carcinoma (human epidermal growth factor receptor 2 (HER 2) positive and oestrogen receptor (ER) positive). A course of neoadjuvant chemotherapy had been completed two months earlier.

Because she was a Jehovah’s Witness, her advanced directive stated that she would not accept blood products. Her medical history included mitral regurgitation, diverticulitis, and autoimmune hypothyroidism for which she took levothyroxine. After extensive multidisciplinary preoperative planning, she underwent successful surgery without the use of blood products. Her haemoglobin was 90 g/L preoperatively (reference range 115-160 g/L; normocytic anaemia—folate, B12, and ferritin were within normal ranges) 122 g/L on admission, and 109 g/L postoperatively.

Questions

  • 1 How should this patient be counselled preoperatively?

  • 2 How could the patient be optimised preoperatively?

  • 3 What measures can help minimise blood loss?

  • 4 Who can the medical team turn to for advice?

  • 5 Is it possible to perform major surgical procedures without the use of blood products?

Answers

1 How should this patient be counselled preoperatively?

Short answer

In the United Kingdom and United States, the autonomy of competent patients must be respected above other ethical principles (this is not the case in all countries) and an individual management plan agreed and formalised with a legally binding advanced directive. The beliefs and opinions of Jehovah’s Witnesses may differ regarding blood derived products and procedures.

Long answer

In the UK and US, the first principle of ethics—autonomy—is placed above all others when agreeing a management plan with a patient. Not all countries share the same values. Although no one would contradict the value of autonomy as a major ethical principle, some countries consider that principles such as beneficence and justice should be included in …

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