Severe Anemia in the Older Jehovah’s Witness An Experience with Two Contrasting Cases

Abstract

Managing anemia in the Jehovah’s Witness (JW) can be a challenging problem for health care providers in light of the reluctance of the JW to accept blood and blood products as a component of medical care. Anemia is not uncommon in these patients and is the result of a discernible cause in many of the cases. While not all causes of anemia are easily correctable, the majority have a well delineated etiology with the potential for management without administration of blood. Providers must learn to recognize the presence of anemia at the earliest, use measures to prevent worsening and implement corrective strategies where possible. Adequate communication between provider and the JW regarding goals and strategies in approach to anemia must occur at the earliest opportunity and continue on an ongoing basis.

Severe anemia is a challenging and potentially lethal problem when the patient is a Jehovah’s Witness, a situation where correction of anemia through transfusions is contrary to religious principles.  It is all the more necessary to offer the patient guidance regarding alternate options to manage anemia in this setting. The need for residents and fellows in training to be educated on dealing with anemia in the Jehovah’s Witness is equally important. When asymptomatic and healthy, people of any culture or religion tend to be less concerned with their beliefs in relation to health care; however, during severe illness or towards time of death, there may arise a state of ”spiritual urgency”.  It is vital for health care providers to recognize, support and embrace spiritual concerns of patients and caregivers, irrespective of their religion and beliefs.  It is conceivable that some providers are uncomfortable or reluctant to adequately treat such patients; this fear may be even more apparent for trainees and physicians ignorant of beliefs of the JW. The house officer who spends the night convincing a Jehovah’s Witness to violate one’s religious beliefs is not only not aiding the patient, but contributing to an uncomfortable patient-doctor relationship.

Jehovah’s Witnesses believe in the Almighty God, Jehovah.  Founded in 1870, the group took the name “Jehovah’s Witness” in 1931. In 1945, the Watchtower Bible and Tract Society (WBTS), the overseeing body for Jehovah’s Witnesses, determined that accepting blood and blood products for medical therapy violated teachings of the Bible and prohibited the receiving of blood transfusions. ¹   There are nearly 1 million Jehovah’s Witnesses in the U.S. and more than 7.1 million worldwide actively involved in preaching. ¹

We report our experience on two Jehovah’s Witnesses that were cared for in our setting within 6 months in a teaching hospital, demanding differing strategies in managing severe anemia.

Case 1

92 year old female with hypertension, chronic kidney disease (CKD) stage 4, coronary artery disease (CAD), heart failure and anemia, was hospitalized with severe weakness. Her lab values were hemoglobin (Hgb) 7.6/g/dL, hematocrit (Hct) 22.2%, creatinine 2.5 mg/dL. Ferritin, B12 and folic acid were normal. She was apparently anemic for years. She was a Jehovah’s Witness who lacked capacity; her health care proxy refused transfusion, respecting patient’s expressed wishes. She developed Clostridium difficile colitis, complicated by intestinal perforation, requiring surgery. As family refused transfusions, surgery was not performed; the patient expired shortly thereafter.

Case 2

85 year old female with anemia, right sided stroke, dementia and hypothyroidism, was hospitalized for rectal bleeding requiring gastro-duodenoscopy and colonoscopy. She apparently had a history of dark colored stools intermittently. Lab: Hgb 8.6/g/dl, Hct 24%, Cr 1.0 mg/dL; ferrokinnetics confirmed iron deficiency, with transferring saturation of 13% and serum ferritin of 14 ng/ml;  B12 and folic acid were normal. Evaluation confirmed a well differentiated rectal adenocarcinoma. Prior to surgery, correction of anemia was required by the surgeon; intravenous iron provided in the outpatient setting improved Hgb to 10.7g/dl and Hct to 33.3%. She was now again hospitalized for elective surgery.

Discussion

The cases raise several questions regarding the management of patients who cannot receive blood products. What are their special needs in the medical setting and the best medical practices for addressing anemia and handling blood loss? What are the ethical and legal implications in such cases?

The WBTS specifically prohibits whole blood. ^{1 2}   Components such as albumin, fibrin, bone marrow, stem cells, dextrans and oxygen carrying blood substitutes are more acceptable; the true solution is in providing sufficient oxygenation until the marrow recovers to make red cells. ²   High variability appears to exist among individual Jehovah Witnesses with regards to acceptance or refusal of different components. Caregivers should be aware of the general principles, comfort level of the patient and discussions pertinent to rejection or acceptance of blood products, administered with the sole purpose of improving their health. There is also a need to be aware that there are ways to correct anemia or raise the hemoglobin level by means other than transfusions, and in a timely manner prior to becoming ill and requiring hospitalization or surgery.

A sensible approach would include the early detection and evaluation of anemia, through basic tests and attempts at correction; in two-thirds of older adults with anemia, a cause is readily discernible ^{3 4}  and a diagnosis can be made utilizing basic blood tests. ⁵   Providers should obtain a focused medical history that includes: family history (e.g. hemoglobinopathy or cancer), nutritional intake, history of blood loss from gastrointestinal or genitourinary sites, and the use of medications that promote blood loss or nutrient malabsorption. The etiology of anemia can be ascertained through basic diagnostic tests. In addition to hemoglobin and hematocrit, white cell and platelet counts, one must obtain tests for kidney, hepatic and thyroid function and a status of iron (ferritin and transferrin saturation), folic acid and vitamin B12 stores. Anemia in older adults is really a marker of illness rather than attribute the condition to aging. Of the known causes of anemia, a third is nutritional in origin and readily treatable, while a significant number has chronic kidney disease, where anemia can be addressed. ^{3 4 5}  Impaired renal function is common in older adults and anemia becomes increasingly frequent with CKD stages 3 and worse; anemia of renal origin responds to erythropoietin stimulating agents (ESAs) coupled with iron supplements. ^{5 6}   Efforts at evaluating anemia may be more worthwhile in the JW if instituted in the outpatient setting, when the patient is stable and prior to the development of acute illness and hospitalization.

Erythropoietin is a hormone produced predominantly in the kidney (90%); hypoxia and anemia stimulate erythropoietin production, with a threshold around Hgb of 10 g/dl. The management of severely anemic patients with erythropoietin is expensive; use of erythropoietin should be limited mainly for anemia of CKD, taking care to avoid overcorrection, as higher hematocrits from the use of erythropoieitn are now known to be associated with adverse events. ^{5 6}

Our cases present differing scenarios; in case 1 with anemia of CKD (stage 4), a role for the use of iron and ESA was apparent and may have benefited the patient; in case 2, an older female, with iron deficiency, intravenous iron markedly improved the hemoglobin in a timely manner prior to surgery.

Iatrogenic blood loss from blood tests during hospitalization is a factor that can hurt the JW and must be kept to a minimum; blood tests must be ordered solely in the situation where they are likely to alter management.  Blood samples taken several times daily may mean even a liter blood loss over days; and packed cell volumes take time to recover. ⁷   One should screen when deemed appropriate, for occult blood loss, control infections as they occur (as they contribute to anemia) and take a cautious approach to hazardous activities or sports that predispose to trauma. ⁸

In managing anemia in the JW, when transfusions cannot be utilized, the challenge to the physician is to seek alternative care solutions earlier rather than when it is too late.  Prompt and open discussions must take place about all available options and solutions. One must attempt to find a means to bridge the time gap until the patient’s bone marrow can recover to produce acceptable hemoglobin levels. Examples are time taken for marrow injury from an insult to abate (e.g. drug toxicity), or nutrient replacement and the time to bear results (e.g. administration of iron, folate or B12), with care taken to avoid further insults during the time of recovery. Measures should be directed to promote erythropoiesis and improve oxygenation. Care must be taken to minimize adverse effects of medications. Education of patient, caregiver and provider plays an important role in the overall care, with a need for re-enforcement periodically.

Although the alternate choices to transfusion are limited, much can still be done to prevent morbidity in these patients. As JW are aware that cannot receive transfusions for severe anemia, focus may instead be emphasizing healthy lifestyles. Jehovah’s Witnesses need to understand the relevant principles consistent with healthy living. They may maintain personal hygiene and adherence to routine measures to prevent infections (such as hand-washing) on a daily basis. JWs should be educated regarding a healthy diet, including the use of fresh fruits or vegetables; it should be emphasized that folic acid is easily lost during cooking. JW patients should observe safety precautions (seatbelts and speed limits) to prevent accidents or trauma, consequent blood loss and ultimately a consideration for transfusions. They should refrain from tobacco use to prevent hypoxia and diseases linked to smoking; in these instances (coronary artery disease or chronic obstructive lung disease) oxygen saturation is important. Anemia and consequent hypoxia can be compounded by smoking related injury. Alcohol excess can lead to folic acid deficiency, yet another cause for anemia.  Medications such as non-steroidal anti-inflammatory agents, aspirin, other anti-platelet agents and anticoagulants must be used with caution in the JW with cardiovascular disease, as the risk of bleeding from these medications may impose a higher than usual risk. The main adverse event from these medications is bleeding, and the question of transfusions to correct severe blood loss may come up. One must not take the extreme step of completing avoiding anticoagulants or antiplatelet agents; rather these drugs should be used with caution after considering the risk benefit ratio as being favorable to the patient. Use of anticoagulants and antiplatelet agents must be with extreme caution in the anemic JW who refuse blood products.

Early initiation of antimicrobial therapy, adequate source control, and close surveillance for wounds or hematomas to prevent bleeding and control of catheter related infections are considerations in all settings. Prophylactic agent use deserves caution. For e.g. H2 receptor blockers have been associated with thrombocytopenia; antibiotics also cause B12, folate and vitamin K deficiency, all of which may lead to anemia through malabsorption. The patient’s own red cell production can be enhanced through the use of erythropoietin in the presence of CKD, or with the use of iron, vitamin B12, and folic acid in presence of the specific nutrient deficiency. Every patient with anemia must have a comprehensive plan to prevent development or worsening of anemia and its associated co-morbidities,.

Ethically speaking, courts have upheld the rights of competent adults who refuse lifesaving treatment. Prudence requires that we identify JWs early; health care providers should make every effort to implement advance directives (living will or health care proxy) and ascertain available written or oral statements of the patient. This is feasible in the outpatient setting, and in an elective manner. Claims of lack of capacity or competency have to be proven or substantiated by experts and time made available for decision making. ^{8 9}   The process of consultation, discussions and decisions influencing management require documentation, preferably witnessed; a multi-disciplinary approach may be beneficial. ^{8 9 10}   Following refusal of blood transfusion, and weighing the risks and benefits, if a procedure appears risky in presence of severe anemia, the patient should not be compelled to undergo surgery. This approach was apparent in case 1, where surgery was not possible; in contrast with case 2, elective surgery was offered following correction of anemia. Some considerations in the management of the JW are provided in Table 1.

Learning Points

• Recognize and understand preferences of Jehovah’s witnesses at the earliest; they must include the presence or absence of advance directives
• Attempt early evaluation of anemia, address its etiology and where appropriate the role for replacement of nutrients or use of erythropoietin (in CKD).
• Formulate a plan to minimize blood tests and blood loss in all settings.
• Implement measures to promote a healthy life style and appropriate medication use.
• Solicit help from liaison committees including Jehovah witness friendly physicians to facilitate care.

Table: Considerations in Managing Jehova’s Witnesses

• Caregivers should be aware of comfort level with discussions with the patient regarding rejection or acceptance of measures, especially blood products.
• The sole purpose of management should be to improve the JW’s health.
• Anemia should be detected at the earliest through basic tests.
• Evaluation must be directed towards the etiology of anemia.
• Blood loss must be minimized at all settings, including through blood tests; screen for occult blood loss where indicated.
• Education must be provided regarding healthy lifestyle, including hygiene and nutrition.
• Medications such as anticoagulants, antiplatelet agents and analgesics (NSAIDs) must be used with caution.
• Correct nutrient deficiencies where possible.
• Address anemia resulting from CKD, through use of erythropoietin.
• Health care providers should make efforts to offer opportunity to implement advance directives electively and at the earliest.