The rise of bloodless medicine: how we treat those who cannot receive blood products for religious reasons or others

[Bible Speaks]

Important article
The rise of bloodless medicine: how we treat those who cannot receive blood products for religious reasons or others
To Carlton D. Mill, Joseph J. Shatzel and Thomas G. Deloughery

The Discovery of the characterization of blood and the subsequent ability to infused blood safely has revolutionized medicine and has allowed people to survive lethal bleeding complications related to surgery, traumatic and non-traumatic injuries and even pregnancy.

While the transfusion has been beneficial to many patients, there are persons who, for religious or other reasons, reject blood products. This, in addition to the growing knowledge of certain risks associated with transfusion, has led to innovative approaches to the handling of blood loss.

As a result, among the health institutions, there is an increasing number of "Non-blood medicine" programmes that focus primarily on the best way to pay attention to patients who reject blood-derived products, the most common of which They're Jehovah's witnesses. Our group of medicine recently published our own best practices in several areas relevant to the care of these patients, including and intraoperative management, acute blood loss, trauma, pregnancy and malignancy.

Focus on non-blood

One of the central principles of medicine without bloodshed is to establish the individual beliefs of a person before he enters a situation related to blood loss, more commonly the surgery. However, establishing what a person is willing or unwilling to accept can be difficult. In Modern medical practice, human blood components (including red blood cells, platelets and coagulation proteins) are separated using laboratory techniques in what is known as "fractions" of blood, either of which can be transfused Of a particular patient needs

While there may be general rules regarding transfusion within a given religion, individual members may accept different fractions of blood depending on their own specific beliefs. However, some patients may have little or no knowledge of the blood fractions or the transfusion alternatives available to them. For this reason, patients in our institution can meet with a member of our medical program and an associate member of the religious community (as a representative of Jehovah's witnesses of the local hospital liaison committee) to help analyze the Transfusion. And their alternatives in detail and to help make decisions about acceptable treatments that align with the objectives of that patient.

We and others have suggested that this meeting be conducted in private with the patient only to avoid any coercion from third parties, including family members (patients may also opt to receive transfusions in private). This information on patient preferences can be used to facilitate discussions with surgical equipment, anesthesiology and in order to create a strategy for surgery and post-operative care.

Medical optimisation is also critical. Before surgery, we examine all patients to detect anemia and treat any underlying iron or vitamin deficiency that could be contributing to the decrease in the production of blood cells. If the patient is ready, we can also provide a hormone called erythropoietin (EPO) to help increase red blood cell levels, a treatment that is currently approved by the FDA for anaemic patients undergoing certain types of high-risk elective surgery. During surgery, a number of medical, surgical and anesthetic techniques may be implemented which relate to the reduction of bleeding.

What to do during the acute blood loss?

However, it remains particularly challenging when significant acute blood loss occurs, including bleeding that emerges after the operation, as well as traumatic and non-traumatic injuries. As the bleeding progresses, it decreases hemoglobin (a vital protein in red blood cells transporting oxygen to body tissues) and increases the risk of mortality.

Although the minimum haemoglobin required to maintain life is unclear, a Jehovah's witness study that rejected blood products after surgery showed that some patients were able to survive with the least amount of hemoglobin of 2.1-3.0 GRAMS PER DECILITER, which It's about 15-25 % normal. This suggests that even in the context of deep blood loss, transfusions are not the only option for survival.

In Case of acute bleeding, medical care providers must simultaneously search for what blood products they want and do not want to receive a patient (if not known or documented), provide resuscitation (such as intravenous fluids or other medicines to improve blood pressure) , reduce the additional blood loss (including the reduction of blood thinners and investigate the source of bleeding through surgery, images or endoscopy) and reverse any deterioration of the underlying coagulation (such as those related to the use of anticoagulants).

If a patient is willing, we can also provide other products to help stop bleeding, including medicines that inhibit the breakdown of the clot (such as acid, which is particularly beneficial in trauma-related bleeding) as well as derived coagulation factors Of the laboratory (as recombinant factor viia, which is produced from modified hamster cells containing the human coagulation gene, factor vii). Although it has not yet been approved by the FDA, our center also has experience in the use of "Oxygen-based oxygen transporters", which is an artificial blood substitute using hemoglobin derived from bovine animals to help transport the oxygen by the Body.

Pregnancy is another common area where non-blood drugs can provide benefits. Post-partum haemorrhage occurs in about 11 per cent of pregnancies worldwide, and is the main cause of maternal death worldwide, with studies showing that the risk of bleeding mortality is significantly higher for witnesses From Jehovah. Given the increased risk of complications, adequate prenatal preparation is essential at the beginning of pregnancy (generally under the care of an obstetrician familiar with high-risk pregnancies) to help ensure safe birth. This preparation includes appropriate advice, treatment of underlying anaemia and active collaboration with anesthesiologist and haematological.

If a post-partum haemorrhage occurs, it can be treated with intravenous fluids, medicines, repair of lacerations and manoeuvres such as uterine massage. If these measures do not control bleeding, invasive procedures or surgeries may be performed, including hysterectomy as a measure of last resort. Of particular interest, the recently completed woman study, which is a clinical trial of more than 20,000 women with postpartum haemorrhage, found that acid significantly reduces mortality, particularly if it is administered within 3 hours of the start of Bleeding.

Although not associated with the obvious loss of blood, cancer patients can also benefit significantly from drugs without bloodshed. Modern chemotherapy can have impressive healing rates in some cancers if it is aggressively treated. However, this often results in side effects related to chemotherapy, as well as severe anaemia and low platelets, of which patients may require significant transfusions to survive their treatment.

This poses a challenge to those who can potentially be cured but who reject blood products, because modifications to chemotherapy (such as dose reduction), although more tolerable, can compromise the ability to achieve healing; handling these Patients are extremely complex and should be considered on a case-by-Case basis. In patients for whom the purpose of treatment is not curative (i.e. a "palliative" Strategy), we recommend adjusting chemotherapy in such a way that it does not require transfusions. Notably, small studies and reports of patients with cancer of Jehovah's witnesses have reported a favourable response to treatment when they are supplemented by aggressive support measures and tolerance to the court of significant anaemia.

While patients who reject blood products may present significant ethical and medical challenges for health care providers, the risks of harm and death can be significantly reduced with careful and extensive planning. Ideally, this takes place long before an early event related to blood loss or anaemia, including elective surgery, pregnancy and cancer treatment. With progress in our understanding of anaemia and the advent of new medicines, surgical techniques and support support measures (including early detection and careful handling of anaemia), these patients can be successfully treated in a "No-spill" way Of blood ". although some of these novel treatments only have limited data to support their use, these interventions should still be considered if the bleeding threatening life persists despite other measures.

This study, treatment of individuals who cannot receive blood products for religious or other reasons, was recently published by Carlton D. Mill, Joseph J. Shatzel, Thomas G. Deloughery in the American Journal of hematology.

GOOGLE TRANSLATED –

https://sciencetrends.com/rise-bloodless-medicine-treat-cannot-receive-blood-products-religious-reasons/

[Bible Speaks]

http://www.anbariloche.com.ar/noticias/2017/12/01/61770-jueza-autorizo-transfusion-de-sangre-a-un-nino-hijo-de-testigos-de-jehova

[Queen Esther]

We  can't  read  the  Spanish  text  by  that  link,  @Bible Speaks... sorry,    I  always  translate  the  Text  for  our  members   Its  not  a  big  deed  over  google !

[Queen Esther]

http://www.anbariloche.com.ar/noticias/2017/12/01/61770-jueza-autorizo-transfusion-de-sangre-a-un-nino-hijo-de-testigos-de-jehova

TRANSLATION  FOR  OUR  ENGLISH  SPEAKING  MEMBERS....

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Family judge María Marcela Pájaro authorized a blood transfusion of a 6-year-old boy whose parents profess the cult "Jehovah's Witnesses."

The decision adopted was based, in particular, on the right of every child to live as laid down in Article 6 of the Convention on the Rights of the Child and on the state of health proposed in Article 24 of the CRC, the latter being the right to enjoy the highest possible level of health and care for diseases and health rehabilitation.

It should be noted that the petition was made by the lawyer of the Hospital of Bariloche at the request of a pediatrician treating the child. For this reason, she took turns calling the minors' defense lawyer and the family judge to clarify the emergency situation of the little boy who, according to his picture, asked for a transfusion of red blood cells that the parents did not want to be members of the cult "Jehovah's Witnesses".
It should be remembered that those who profess to have this religion give written authority to avoid transfusion if treated in this way.

Following admission to the hospital and after talking with the pediatrician and talking with relatives, permission was granted for the transfusion with the consent of the youth advocate, without the consent of the attending physician that the transfusion would be used. Yes and only if it was important.

It should be noted that an attempt was made to contact the child, but when he realized that he was resting and alert at his young age, it was considered unnecessary to disturb his calm.

The resolution stated that this right conflicts with the right of parents to profess religion and educate their children under the commandments of that faith. In this sense, it was mentioned that "the parental responsibility that the law imposes on the head of the parent must be exercised in accordance with the guiding principles of the CCF 639. Parents of children under 13 always exercise legal representation and if their decisions Do not endanger the child, as it is a right, but in principle a duty when personal rights are concerned, there is a limit to the fact that no right is absolute, nor that arising from parental responsibility.

It was also noted that "General Comment No. 7 of the Committee on the Rights of the Child, which deals specifically with the realization of the rights of children in early childhood, includes the objectives of local customs and practices except in cases that infringe the rights of the child (Objective 2 (e)).

Judge Pájaro's ruling recalled that "... the powers of transfusion of persons who profess the religion of Daniel's parents are recurrent in our courts, although the 1993 Supreme Court has resolved the Bahamondez case. that "... it is interesting to note that there were different foundations and that some judges believed that the question was based on the provisions of Article 19 of the Magna Carta, while others in the freedom of worship. Regardless of this, and regardless of the basis to be taken, it is clear that judges should not interfere in the decision taken by an adult, fully aware of the consequences of his decision, in full compliance with informed consent ... "

The situation is different for children, as has been reported, and for children with disabilities who can not comment, even more sensitive. In this case, features are added that increase their vulnerability: short age, disability and a specific pathology that has not yet been determined. "... the fact that their parents confess a certain religion does not allow them to think that they are the owners of their son just because they conceived him ..."

It should be noted that the parents, informed immediately of the court decision to authorize the transfusion, stated that they would comply without objection, that they understood the reasons and that they appreciated the work and the humane and ethical treatment of the pediatrician.

The parents did not interfere with the transfusion, but considered that they could not give their consent, so for that reason, the judge in the use of the faculty that accepts the law has suggested that this was the best alternative for the child ,

"... Everyone has the right to confess the cult he wants and to make decisions about his health only with the restrictions set by the law, as long as they do not make free and voluntary decisions
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In the main, this is the heart of the resolution and, depending on the rights in dispute before weighing the interests affected, it was necessary to authorize the practice. This is because the State -which the Family Judge represents- has the non-derogable responsibility of ensuring the human and personal rights of all persons and even more of those in special vulnerable condition. (ANB / ANR)