1. T HE J EHOVAH ’ S W ITNESS James Peerless CT2 Anaesthetics Trainee November 2011

2. O BJECTIVES History & background of JWs Beliefs surrounding use of blood products Anaesthetic assessment & peri-operative care Alternatives Capacity

3. B ACKGROUND

4. H ISTORY Founded in 1872 by Charles Taze Russell Pittsburgh, Pennsylvania Formation of Zion’s Watchtower Tract Society Renamed Jehovah’s Witnesses in 1931

5. B ACKGROUND Bible study group that has grown to include 12 million members worldwide Perhaps best known for making house-calls and evangelising Several watchtower publications and Awake! magazine which provide guidance on how to live one’s life

6. A BOUT THE J EHOVAH ’ S W ITNESSES Use a version of the Bible called: “The New World Translation of the Holy Scriptures” Do not accept the concept of the Trinity Do not celebrate Easter, Christmas or birthdays Believe that the Armageddon is imminent Refuse military service Refuse blood products

7. W HY DO THEY REFUSE BLOOD ?

8. L EVITICUS 17:11-12 11 For the life of a creature is in the blood, and I have given it to you to make atonement for yourselves on the altar; it is the blood that makes atonement for one’s life. 12 Therefore I say to the Israelites, “None of you may eat blood, nor may any foreigner residing among you eat blood.”

9. G ENESIS 9:3-4 3 I have given them to you for food, just as I have given you grain and vegetables. 4 But you must never eat any meat that still has the lifeblood in it.

10. A CTS 15:28-29 28 It seemed good to the Holy Spirit and to us not to burden you with anything beyond the following requirements: 29 You are to abstain from food sacrificed to idols, from blood, from the meat of strangled animals and from sexual immorality. You will do well to avoid these things.

11. B LOOD Watchtower Society banned its members from receiving blood in 1945 Have been many technicalities as to what is and is not acceptable as medical knowledge has progressed Not necessary logical, so it is important to check with each individual and not make assumptions Now movements within the Watchtower to change practices

12. W HAT IS BLOOD ? Red cells White cells Platelets FFP Whole blood Autologous storage Cell salvage Haemodialysis Cardio-pulmonary bypass Blood fractions Albumin Immunoglobulins Clotting factors Organs Epidural blood patches The “Big Four”Individual Choice

13. A NAESTHETIC A PPROACH

14. G ENERAL G UIDANCE Elders sit on the ‘Hospital Liaison Committee for Jehovah’s Witnesses’ in each hospital Provide guidance for you and the patient Consultants (anaesthetic and surgical) should be ideally involved throughout Discussion with patient alone Document all discussions with the patient in the notes, and get them to sign it too. Special consent form for Jehovah’s witnesses

16. E LECTIVE S URGERY Should be flagged up at pre-admission to aid with planning Consultant allocated to the case Patient has to have informed consent Investigate and treat any anaemia Iron Erythropoetin Staggered procedures to allow for recovery

17. E MERGENCY S URGERY Similar to elective care, as time permits Optimise wherever possible Capacity issues Advance directives Don’t make isolated decisions

18. I NTRA - OPERATIVE C ONSIDERATIONS Communication between surgeon and anaesthetist Positioning Tourniquets Hypotensive anaesthesia Haemodiltuion Optimised clotting Normothermia Avoid acidosis Cell salvage Pharmacological Vasoconstrictors Tranexamic acid Recombinant Factor VIIa

19. P OST - OPERATIVE C ARE Strict monitoring and low threshold for return to theatre if bleeding suspected Mechanical ventilation to optimise O2 delivery Active cooling to reduce metabolic demand Hyperbaric oxygen therapy (increased dissolved fraction)

20. C APACITY

21. C APACITY & C ONSENT All adults are assumed to have capacity Principles: Understand the information Retain the information Process the information Communicate their wishes

22. C HILDREN <16 yrs Parents’ consent vs. Gillick competence Can agree to treatment, but not refuse it Special Issue Order Obtained via the High Court if time allows Emergency situations mean treatment proceeds in best interests of the child, regardless of parents’ wishes 16-18 yrs Treated as adults with regard to medical treatment

23. S UMMARY

24. Y OUR RIGHTS Can refuse to treat an elective patient Duty-bound to involve another anaesthetist with appropriate ability Expected to care for an emergency patient, to find out their wishes and abide by them Increased stress

25. S UMMARY Different JW patients will have different interpretations on what is acceptable Always document meticulously, and include colleagues in the decision making – no decisions should be made alone Balance between respecting a patients’ wishes and diverting care and resources away from others

26. R EFERENCES www.watchtower.org (accessed 31.10.11) The Association of Anaesthetists of Great Britain and Ireland (2005). Management of Anaesthesia for Jehovah’s Witnesses, 2 nd Edition. McCombe K, Wijayasiri L, Patel A (2010). The Primary FRCA Structured Oral Examination Study Guide 2. Oxford: Radcliffe Publishing