Canadian Medical Association Journal 1996; 154: 557-560
On a Friday afternoon in mid-November, about 15 mostly obstetric and gynecology residents filed into a lecture theatre at Dalhousie University medical school in Halifax. They had just attended a seminar on blood transfusion, and now were about to hear a different perspective on the use of homologous blood. "We believe in the power of prayer, but we also believe in the medical profession, and we want good medical care," Dennis Charland told them. "It's just blood transfusions that we decline in favour of nonblood medical management."
Charland is director of hospital information services for the Watch Tower Bible and Tract Society of Canada, which represents more than 200 000 Jehovah's Witnesses. He and some of his colleagues were at Dalhousie to give a presentation, "Meeting the challenge of nonblood medical management." It is part of a larger effort to educate the medical community about the Jehovah's Witness position on blood and to promote "bloodless" medicine and surgery in Canada. In recent years, Charland and other Watch Tower representatives have visited more than 10 medical schools and 200 hospitals across the country.
This was their third appearance at Dalhousie, where their presentation is now part of an undergraduate curriculum unit. Charland provided students with a brief overview of the medical interventions Jehovah's Witnesses will and won't accept, and then explained the biblical basis for their beliefs. He also discussed the ethical issues surrounding the doctor-patient relationship and the treatment of Jehovah's Witness children, and described how his organization -- through access to experienced specialists, hospital liaison committees, and online research -- can assist physicians in caring for church members.
"Worldwide," he said, "there are some 100 bloodless medicine and surgery centres or programs offered in tertiary, regional and teaching hospitals." There are 52 of these hospitals in the United States alone, which assure patients that blood will never be used. As one ob/gyn resident remarks later in the session, "these centres must be inundated with people - everyone wants [to go] bloodless these days."
That trend has not been lost on Charland and his colleagues, and they believe it's only a matter of time before bloodless medicine and surgery programs begin to emerge north of the border. "In Canada, we don't think it's a question of whether," Charland said. "It's a question of where first."
Bloodless medicine and surgery programs "embrace all the specialties where blood transfusions could become a consideration," he says. According to Watch Tower literature, the programs include a coordinator, "a core team" of specialists willing to treat patients without allogeneic blood, hospital policies and procedures that facilitate patient care (such as patient forms and identification), and mobilization of appropriate treatment techniques and protocols.
He adds that many hospitals have implemented various components, and four want to take a more "formalized or institutionalized approach." But it hasn't been an easy sell. Although blood usage has been decreasing here, Charland says Canada is "conspicuously absent" from the list of more than nine countries where bloodless programs have been set up in response to the needs of Jehovah's Witnesses and the wishes of other patients.
He cites several reasons for the lukewarm reception. "At first glance there isn't an immediate financial incentive," he says. "Administrators and doctors in Canada have a difficult time visualizing how this saves the system money. . . . Many are working with the old myth that blood is free. They're not looking at the direct or indirect cost of blood-transfusion therapy."
Furthermore, he says, many physicians "too quickly conclude that these programs are for Jehovah's Witnesses and that we are adequately cared for or that the patient population requesting nonblood medical management is too small to merit the effort. In reality, there is a growing population that wants bloodless medicine and surgery, and it minimizes the liability concerns associated with transfusions."
Dr. Gershon Growe, medical director of transfusion services at Vancouver Hospital and Health Sciences Centre, acknowledges that "patients have come into the hospital who have requested no blood who are not Jehovah's Witnesses. Probably most [doctors] would try to cut a deal to intervene [with blood] if a life-threatening situation occurs, and probably most of those patients would agree to that."
In the case of Jehovah's Witnesses, he says, the Vancouver Hospital introduced blood waivers in 1970. Today, according to Charland, the hospital also identifies such patients through wristbands, and a note indicating No Blood or Blood Products is entered in the patient-information system. "I'm not sure [a bloodless program] would be necessary here," Growe concludes. "Most of the elements are already in place, and most of our surgeons and anesthetists would go the distance for anyone who doesn't want blood. If somebody won't do it, they would transfer the care to someone else."
"I don't see these programs serving any useful purpose," adds Dr. Peter Pinkerton, director of clinical pathology at Sunnybrook Health Science Centre in Toronto. "What we should be doing is trying to reduce transfusions across the board. This concept is the extreme end of a continuum. . . . You can carry this too far - you can start denying transfusions to people who should really receive them.
"Obviously with Jehovah's Witnesses you have to respect their religious beliefs and refrain from giving any blood product, but [for] any other patient you give them as little as you can reasonably get away with [while] maintaining their clinical condition."
On the other hand, suggests Dr. Mark Boyd, bloodless programs may have beneficial side effects. Boyd, head of gynecology at the Royal Victoria Hospital in Montreal, has performed more than 500 procedures on Jehovah's Witnesses and can recall only one of his non-Witness patients being transfused in the past 5 years. "I think it's positive," he says of bloodless programs. "Blood isn't a popular product, particularly in the last decade."
Boyd recently completed a study of 100 hysterectomy patients who refused blood transfusions, and about 10% were not Jehovah's Witnesses. He says all did well and left the hospital at the same time as patients in the control group. Furthermore, of the 10 control patients who received blood, 8 transfusions "were unnecessary." Boyd, who is not a Jehovah's Witness, believes bloodless programs could make physicians more aware of preventing the need for transfusions in other patients. "The recognition that it's possible to do these things and to formalize them and have people try to make decisions before an actual crisis is important," he says. "There's nothing radical about the Jehovah's Witness approach, and everybody is capable of it . . . but it's not something that everyone is comfortable about doing."
Dennis Charland says treatment of Jehovah's Witnesses has improved over the past 10 years -- the Watch Tower Society's list of Canadian specialists now numbers 1200 and few patients have to travel to the US -- "but it doesn't mean there's no difficulty in getting bloodless medicine and surgery in Canada."
A common obstacle, he says, is lack of knowledge about therapies Jehovah's Witnesses will and won't accept (autologous donation and storage and transfusions of whole blood or the three principal blood components are taboo, while plasma fractions and other procedures are left up to the individual).
Charland says there have been a number of cases in Canada in which Witness patients have told hospitals they want no transfusions, but then are not adequately identified either through wristbands or on the medical chart and inadvertently are given blood. "Obviously that has a tremendous emotional impact on the patient," he says, "and it raises questions of liability."
Another difficulty arises with emergency care. Treatment protocols are often lacking, leaving physicians "at a bit of a loss." Within bloodless medicine and surgery programs, "the procedure is established, trauma specialists in the hospital willing to provide that kind of treatment are identified . . . and treatment proceeds expeditiously."
Since 1984, Dr. Mervyn Thomas, an obstetrician in Nanaimo, BC, has served as an expert witness in about 50 court cases involving Jehovah's Witnesses who have died, been transfused against their will or encountered "some medicolegal hassle." The more common cases appear to involve bleeding from gastric ulcers or women dying during childbirth, he says, citing a current case involving the death of an Ontario woman.
"One of the major problems with the treatment of Jehovah's Witnesses is delay," he explains. "Up to now, doctors have argued, `Well, if you can't take blood, if you want me to operate with one arm tied behind my back, we can't do it -- you'll die.' They stand around and argue with the patient or the relatives, and time is slipping by and the patient's bleeding."
Thomas hasn't given a blood transfusion since he became a Jehovah's Witness in 1971. He says he hasn't lost any patients, although he recalls "chewing his fingernails" when one patient's hemoglobin level dropped to about 30 g/L. He says Jehovah's Witnesses don't encounter many problems in the Nanaimo area, thanks largely to the presence of him and a few other physicians who have educated area doctors.
Today, however, Thomas is 75 and on the verge of retirement. He would like to see a bloodless program in place at the Nanaimo Regional Hospital, and is surveying specialists "to see who is willing to treat patients without blood, so . . . the hospital knows, the medical staff knows, and any patient who wants to know can go to someone without any hassle."
"It would be a great saver of time and effort if we knew in advance which surgeons, obstetricians, anesthetists would be prepared to undertake the care of such patients," says Dr. Robin Hutchinson, medical coordinator at the hospital.
He says the hospital is revising its form for refusing blood and is considering No Blood stickers or other indicators for patient charts. He's interested in the concept of bloodless programs, but is "not sure" about establishing a centre: "We don't want more patients."
In Chicago, however, Jan Castro Graziani recommends "a formal setup." Castro Graziani is coordinator of the Center for Bloodless Medicine and Surgery at Our Lady of Resurrection Medical Center, which was established in 1987 and is the oldest bloodless centre in the United States. She describes the Chicago centre as, essentially, a hospital department. When patients are admitted, they sign the appropriate forms and receive blue wristbands and blue coding on their chart. Then they are streamed into the normal patient population.
She says 42 doctors participate in the program, two in each specialty, and they treat more than 200 patients a year. "Our length of stay actually comes out 1 day less on average compared with other patients with the same diagnosis," she says.
"There's very little that can't be done," she adds, noting that the lowest hemoglobin level she has seen is 18 g/L. The Chicago centre, however, does not perform transplants or accept children, nor does it seek out non-Jehovah's Witness patients. That's not the case at some other bloodless centres, where the proportion of non-Witness patients has reached about 10%.
Since the Center for Bloodless Medicine & Surgery at St. Vincent Charity Hospital in Cleveland opened in mid-1994, 5% of its patients have been non-Witnesses. Director Sharon Vernon, a nurse, hopes the centre will "truly go public" when she finishes developing a consent form that enables patients to choose blood in life-threatening circumstances.
Vernon says some centres in the US "are nothing more than a referral service," while others, such as Our Lady in Chicago and St. Vincent's, are institutionally driven, "with all policies and procedures integrated into all parts of the hospital."
The "whole goal" is to minimize blood loss, she says. This extends from "very selective" laboratory tests -- studies have shown that the average adult receiving intensive care loses a unit of blood a week through tests, she says -- to meticulous surgical techniques. Vernon observes that patients don't have to deal with immune reactions, postoperative infections, other diseases or emotional anxiety caused by blood transfusions.
"People are referring to this approach to patient care as the gold standard," she maintains. "That is exactly what we're looking at. It's through education that you begin to view it that way, because you don't learn it in medical school."
Of the 498 patients the centre admitted in 1 year, 5 died. Indeed, mortality rates at a few other centres appear to be remarkably low. Dr. David Rosencrantz, a urologist who runs a large bloodless program in Portland, Oregon, told Justice Horace Krever in December that his centre hasn't lost a patient even though it has treated 500 to 700 patients annually since it was founded 4 years ago. "From a cost standpoint . . . our patients are out a full day earlier," Rosencrantz said.
Nonetheless, he added, his hospital's bloodless program wasn't an easy sell. It took him 2 years to form a cadre of physicians willing to take part. Most doctors, he told Krever, were resistant. "They didn't want to participate. It was too expensive. It would take too much time." He said 10 to 12 programs in the US are considered "bona fide centres, although more and more are starting for different reasons."
"What these centres promote is more of an attitude," observes Dr. William Pollett, a general surgeon and director of medical education at St. Clare's Mercy Hospital in St. John's. Last fall Pollett attended a national seminar on bloodless medicine at St. Vincent Charity Hospital to learn more about US centres and see if St. John's could offer such a service.
"In most hospitals, a Jehovah's Witness is treated as more of an exception, . . . although I don't think anyone has a problem respecting that exception," he says. "In these [bloodless] centres there is a much more positive attitude, so people are geared up more to advances and techniques for minimizing the need for blood products. Yes, we readily treat Jehovah's Witnesses, but maybe they could be served better in a centre where there is more of this positive attitude." However, he cautions that Witnesses have a "built-in bias" and "we have to recognize that this could go overboard" with other patients.
In any case, Pollett doesn't expect the St. John's Health Corporation to establish a full-fledged centre, although it could embrace many of the elements. "One of the key people in these centres is the coordinator, and I suspect there is not enough demand here to justify having an independent coordinator."
Nevertheless, Dennis Charland predicts that bloodless medicine and surgery programs will begin to surface this year. In the meantime, he and his colleagues plan to continue visiting medical schools and hospitals across the country.
When interviewed in November, Charland was waiting to fly to Alberta to speak to medical students in Calgary, while an associate was staying behind to give the same presentation to second-year students at Dalhousie. "As non-Witness doctors who will be treating Witness patients," Charland told the ob/gyn residents at Dalhousie, "now is the time to start learning [nonblood] management strategies."