Title: What to do when an actively bleeding, adult, legally competent Jehovah's Witness proposed for an urgent surgery consciously refuses a blood transfusion? The Portuguese perspective

Authors: Alves DR, Antunes C, Martins D, Ribeiro P.

Institution: Centro Hospitalar de Lisboa Ocidental, Dept of Anaesthesiology, Lisboa, Portugal

Text:
• Background: Jehovah's Witness patients ordinarily refuse blood products, which leads to important constraints in perioperative management when a blood transfusion is deemed to be life- saving. Different bioethical and legal principles collide in these cases, of which anaesthesiologists caring for these patients should be aware.
• Case report: Female, 65 years old patient submitted to right hemicolectomy for a malignant tumour in the ileocecal appendix. 1 hour after arrival to the postanaesthetic care unit she is hypotensive, oliguric, with ill-perfused extremities, capillary refill time 4 seconds, with active bleeding as evidenced by a haematic drainage of 400 cc. The patient is still neurologically intact, and still refuses a blood transfusion, keeping with her living will determinations previously expressed. The decision is made to reintervene, but abstention from using blood products clearly threatens the vital prognosis of the patient.
• Discussion: In these cases fundamental Bioethical principles collide, namely those of Autonomy, Beneficence, Non-Maleficence and Justice. Because Anaesthesiologists are the last barrier of defence for the patient intraoperatively, it is not surprising that they have to deal with these issues up close, and interestingly an inquiry showed that they were the most likely group to transfuse patients against their will1. Legal codes2 usually reflect Bioethical principles, and they too tend to mirror some of the confusion surrounding the matter in Bioethical terms. Approval of the “Living Will” legislation in Portugal3 has clarified the matter and hierarchized the principles involved in favour of patient autonomy.
• References: 1- Cahana A, Weibel H, Hurst SA. Ethical Decision-Making: Do Anesthesiologists, Surgeons, Nurse Anesthetists, and Surgical Nurses Reason Similarly. Pain Medicine. 2008;9:728- 736.
2- Portuguese Penal Code;
3- Bill 25/2012 dated July 16th.
-Learning points: In light of modern Portuguese legislation, and in line with what has been happening worldwide, patient autonomy must be respected provided it is based on free, informed decisions.

What to do when an actively bleeding, adult, legally competent Jehovah's Witness proposed for an urgent surgery consciously refuses a blood transfusion? The Portuguese perspective