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A real option
Follow one facility’s implementation of a bloodless medicine and surgery program.
By Elizabeth Crum, RN, CCRN, TNCC, MSN, and Jo Valenti, RN

ave Green, 37, was severely his mind. Because of Mr. Green’s Looking back, we realized that

D injured after being hit by a car.

Airlifted to our medical center,
he had a hemoglobin level of 6 g/dL
low hemoglobin level, the trauma
surgeons didn’t want to operate. Con-
sequently, his bleeding was never
some standard nursing care pro-
vided to him was counterproduc-
tive, even harmful. For example, he
and a BP of 65/33 mm Hg on arrival. adequately controlled. Numerous was turned regularly, no one realiz-
But as a practicing Jehovah’s Wit- phlebotomies to obtain specimens ing that this would disturb clots that
ness, he refused blood transfusions for blood work further depleted had formed to halt bleeding. His
and couldn’t be persuaded to change his blood supply. level of arousal was also checked Nursing Management October 2009 39

Going “bloodless”: A real option

frequently, fueling a need for oxy- patient with traumatic injuries who Proactive approach
gen that couldn’t be met by his refuses transfusions. Creating a BMSP for patients who
reduced hemoglobin level. Within refuse blood transfusions took effort,
a few hours, Mr. Green died. This Ironing out problems but it’s paid off. Compare the two
case set off a chain of events in our Jim Dowling, 23, suffered traumatic cases we’ve discussed. In the first,
facility that resulted in a bloodless leg injuries in a work-related acci- nothing was done proactively to
medicine and surgery program dent. Both legs were crushed, with address clinical issues created by
(BMSP). The program wasn’t costly one open fracture and one closed the patient’s refusal to accept trans-
or difficult to implement, and it’s fracture. When he identified himself fusions. Legally and ethically, a
been successfully used to treat all as a Jehovah’s Witness upon arrival, competent adult patient has the
kinds of patients, including those the BMSP nurse was called by the right to refuse any medical treat-
with traumatic injuries. trauma team and immediately met ments, including those that could
with the patient and his family. save his or her life. Under the law,
Talking the talk Mr. Dowling was promptly sent to the patient isn’t required to give
We started with a multidisciplinary the OR for reduction of the frac- a reason or to justify the decision.
group, including trauma surgeons, tures, then to the surgical ICU. The refusal of lifesaving care can
nurses, and blood bank representa- Postoperatively, Mr. Dowling’s be difficult for healthcare profes-
tives, who worked with the Jehovah’s hemoglobin was 5.1 g/dL. He sionals to accept. In Mr. Green’s
Witnesses Hospital Liaison Com- received supplemental oxygen via case, the emotionally charged atmos-
mittee. The church elders in this nasal cannula and was started on phere clouded the judgment of the
group were specially trained in hematinics (I.V. iron and erythro- medical and nursing staff and cre-
medical treatment acceptable to poietin), a treatment that was accept- ated a barrier to optimum care.
Jehovah’s Witnesses. To help build able to him. (Many Jehovah’s In Mr. Dowling’s case, the staff
a successful program from the Witnesses will accept infusions was prepared to take a different
ground up, a nurse who also is a of minor blood components, such approach. Instead of focusing on
Jehovah’s Witness was hired to as albumin clotting factors or what couldn’t be done, we focused
design and implement it. The result immunoglobulins.) Phlebotomies on what could be done. The BMSP
was a BMSP that meets the cultural, were performed very conserva- let us protect the patient’s right to
religious, legal, and clinical stan- tively. Although he was pale and refuse a transfusion while provid-
dard of care for a patient who tachycardic, he had no major prob- ing the best nonblood clinical man-
refuses a blood transfusion for lems. The staff continued to provide agement available.
any reason. appropriate “bloodless” care, and Our facility continues to provide
The BMSP is built on this foun- recognized the patient’s ability to staff development about the belief
dation: tolerate the anemia. At least twice system of Jehovah’s Witnesses and
♦ respect for each patient’s religious, a day a staff nurse from the BMSP acceptable treatment options for
cultural, and personal beliefs visited Mr. Dowling and provided all patients who refuse transfusions.
♦ recognition of his legal right to support. This nurse also worked This program has improved care
give informed consent to medical with the staff and critical care physi- and greatly reduced the frustration
treatment and to refuse treatment cian to clarify issues regarding experienced by staff and patients
♦ development of clinical expert- transfusion-free care, such as mini- because of cultural misunderstand-
ise in stabilizing, supporting, and mizing phlebotomy and continuing ings. NM
treating patients for whom blood supportive measures.
transfusions would otherwise be Mr. Dowling later had skin
indicated. flaps and rod insertion on both Elizabeth Crum is a coordinator of the Cen-
Since 1997, our facility’s BMSP legs. After that surgery, his hemo- ter for Bloodless Medicine and Surgery
has treated more than 3,000 patients, globin level began to climb, and it at Hackensack (N.J.) University Medical
Center, and Jo Valenti is the director of
including many with cancer and remained between 7 and 9.6 g/dL blood conservation at Kennedy Health
sickle cell disease. Patients have for the rest of his hospitalization, System in Stratford, N.J.
even undergone open-heart surgery although he received no blood
and renal transplant in a “blood- products. He was ambulating Adapted from Crum E, Valenti J. Bloodless
less” setting. The following case before his discharge to a rehabilita- surgery an advocate for patients’ rights. OR
illustrates how BMSP can help a tion facility. Nurse. 2007;1(4):17-18.

40 October 2009 Nursing Management