Background: Treatment of acute blood loss in patients that refuse blood transfusion (BT) represents not only an anaesthetic and clinical challenge but an ethical and sociological problem. Jehovah witnesses (JW) refuse BT based on religious beliefs. In our country, it is common for JW to carry an informed and signed consent in which they state their refusal on red cells (RC), white cells (WC), platelets (P) and fresh frozen plasma (FFP) transfusion. 

Case Report:
75 ys woman, JW, history of moderate asthma and dyslipidaemia, proposed for a right hepatectomy to remove a Klatskin tumor with likely cystic invasion. Patient presented an explicit RC, WC, P and FFP transfusion denial in a written consent. As part of the perioperative approach to patients that refuse BT, she received a cycle of recombinant erythropoietin before surgery and presented, at surgery time, with an Hb of 16,4 g/dL, P count of 251x103 /ml and no significant coagulation deficits. Right hepatectomy was performed under balanced anaesthesia with standard monitoring, invasive arterial cannulation, central venous access in left jugular vein and 2 peripheral accesses. No major surgical complication was detected but, due to intraoperative refractory hypotension, noradrenaline (NA) perfusion was started and adjusted according to patient’ needs. Final blood loss of 900ml.

During her stay in the PACU, patient progressively became more hypotensive, with increasing demand of NA and steady rise of arterial lactate. After 2 hours, she was considered to be in haemorrhagic shock due to surgical complication and brought back to the operating theatre to perform exploring laparotomy. Blood sample analysis showed an Hb of 5,1 g/dL and lactate of 5,2 mmol/L at this stage. Packing with haemorrhagic containing compresses was performed. No blood transfusion was administered. After re-intervention, patient vitals continue to drop and she died 4 hours after surgery. 

Discussion and Conclusion: In this case, the team agreed to preserve respect for the patient's autonomy since she had been deemed competent to accept or refuse any proposed treatment, and had been extensively informed about the potential complications of refusal of blood transfusions. However, this refusal may constitute an ethical dilemma for physicians, particularly facing life-threating situations whereas a blood transfusion might save the patient’s life and alternative treatments are unproven or unavailable.

01 / Patients that refuse blood transfusions: clinical and ethical dilemmas on approaching haemorrhagic shock