Answers for the Service Meeting Review of the Video Transfusion-Alternative Health CareMeeting Patient Needs and Rights

1. Why are some in the medical community reevaluating the use of blood transfusions? Answer: An increasing number of patients strongly favor not having transfusions; the risks and costs of blood.
- Today, at least 80 percent of the patients would strongly favor not to have blood transfusions. Both physicians and patients are faced with transfusion complications, supply shortages, and concerns about blood product safety. - As just one example, the World Health Organization calculates that around the globe unsafe transfusion and injection practices cause some five million hepatitis-C virus infections each year. Increased efforts by national health-care systems to achieve a safer blood supply have caused the cost of blood to spiral upward.

2. Give three examples of complex surgeries that have been performed without blood transfusions. Answer: Pediatric open-heart, liver, and orthopedic surgeries.
- Operation on the tiny heart of a ten-month-old baby girl, in Berlin. This child has a congenital heart defect, which is relatively rare. It means there is a direct communication between the left ventricle . . . and the right atrium . . . , which creates a continuous abnormal flow between the left heart and the right heart. The defect was corrected with a heart arrest time of only 26 minutes, and the blood flow normalized. No transfusion was givenin fact, there was virtually no blood loss. - Liver surgery, in Jena, Germany, at the University Clinic; operation to remove the cancerous portion of the liver from an elderly man. No donor blood was given, and 18 hours later, the patient is chatting with the doctor in the ICU. - Orthopedic surgery, in London. Royal College Fellow Peter Earnshaw successfully performs a total knee replacement on an elderly womantypically a high-blood-loss operation. - All three successful operations were accomplished by surgical teams committed to respecting the patients or parents preference that donor blood not be given.

3. How many physicians and surgeons worldwide have indicated their willingness to treat patients without blood transfusions? Why are they willing to do so? Answer: More than 100,000 in 150 countries. Out of respect for their patients decision.
- There are more than 100,000 physicians and surgeons in 150 countries who routinely treat patients without donor transfusion. Some experts feel that every anesthesiologist and surgeon should be interested in blood-conservation strategies because its good patient care. - When physicians who turn to transfusion-alternative health care are asked why, they often cite as a major reasonrespect for their patients decision. There are a growing number of patients who are interested in being treated with either no transfusion or the minimum amount of transfusion possible, and there are some folks who strictly dont want to be transfused under any circumstances.

4. What have recent hospital studies revealed about blood use? Answer: Growing evidence of unnecessary transfusions; less transfusion results in an improved outcome.
- Another area motivating physicians and surgeons to change their approach is the growing evidence of inconsistent practices leading to unnecessary transfusions. As part of a concerted action by the European Commission Medical Research Program, transfusion rates in 43 major teaching hospitals across Europe were analyzed. There were two centers which participated both in the SANGUIS Study and in the BIOMED Study. - Based on their findings in the SANGUIS Study: They had somehow managed to reduce their blood consumption for major surgery. The mortality was the same before and after the changes. The hospital stay was shorter. The new procedures they adopted werent very difficult to adopt, although they took time and took a considerable educational effort, but they didnt result in increased costs. The obvious conclusion is that unnecessary transfusion translates into unnecessary labor and unnecessary cost. Besides patient demand and overtransfusion, many physicians cite as motivation to implement transfusionalternative health care the desire to avoid medical risks.

5. What are the medical risks associated with blood transfusions? Answer: Bacterial contamination, viral infections, suppression of the recipients immune response, and human error.
- Theres the risk of bacterial contamination in a stored unit of blood. Bacterial contamination, whether occurring at donation or subsequently from improper storage, can cause infections having fatal consequences. - In another arena, despite improved testing viral infections continue to pose a serious threat. In addition, blood transfusions induce an immunosuppressive state with the recipient, and that results in increased postoperative infections as well as earlier and more often recurrence of tumors. It was estimated that, approximately, in the United States, we can expect that 10 to 50,000 patients a year may be dying from transfusion-immunomodulation related causes. - Likely the most surprising and least recognized medical risk is human errorgiving blood of an incompatible type can cause a reaction ranging from mild to fatal. Reports indicate that human error causes up to one half of all transfusion-triggered deaths!

6. What conclusion have many experts reached regarding the benefits of transfusion alternatives? Answer: Better patient care; reduced health-care costs; safe, practical, and cost-effective therapies already exist.
- In view of the potential for a better patient-care and reduced health-care cost, blood conservation is not an option, its a must. The good news is that safe, practical, and costeffective therapies already exist. The best medical care can be delivered without the use of allogeneic blood. There are some very simple, very cheap things you can do, which would help the majority of people, and this could be done in the smallest of hospitals. Blood conservation is a very simple method, which makes things rather smooth, less expensive, and with a better outlook for the patient.

7. What causes anemia? How tolerable is it in humans? What can be done to compensate for it? Answer: A low number of red cells in relation to blood volume. Humans can tolerate much lower hemoglobin levels than previously assumed safe. Administer blood volume expanders.
- Racing through the arteries, red cells carry life-sustaining oxygen to all parts of the body. The anemic patient has a low number of red cells in relation to his blood volume. If a person suffers extensive blood loss during surgery or as the result of an accident, the body can tolerate anemia to a considerable degree. - Professor Moore, an acknowledged pioneer in trauma surgery comments: Studies have shown, physiologically, that the human being can tolerate much lower hemoglobin levels than previously assumed safe. - Anemia is tolerable only when the body has sufficient circulatory volume to continue to function. We also know that with that anemia, we can compensate with volume, because volume is the critical component here to maintaining blood pressure. With low-cost blood volume expanders being available, current medical opinion increasingly abandons the arbitrary rule, proposed back in 1942, that a hemoglobin level of 10 was the transfusion trigger, or the lowest acceptable figure before administering a transfusion.

8. How can red-cell production be stimulated in a patients body? Answer: Iron supplementation. In certain cases, the drug erythropoietin (EPO) may normalize the blood count. [Please note that in some countries EPO contains albumin derived from blood. Whether a Christian accepts such treatment is a matter of conscience.]
- The second important principle in transfusion-alternative strategies involves stimulating red-cell production in the patients body. This is important for an anemic patient before surgery, and it can speed recovery after extensive blood loss. Sufficient iron supplementation can already normalize the blood count to a large extent and at relatively little expense. - In selected cases, the genetically engineered drug erythropoietin, commonly called EPO, can be used. Stimulated by the administration of erythropoietin, there is an acceleration of production of new red blood cells.

9. What techniques are being used to minimize blood loss during surgery? Answer: Meticulous surgery, electrocautery devices, drugs that reduce bleeding, and intraoperative cell salvage. [Note: Some products and procedures are a matter of conscience.]
- The most important technique to control bleeding is to avoid bleeding. Meticulous surgery is practical and cost-effective. A variety of tools can be used to assist. For example, electrocautery devices enable surgeons to cut rapidly and to seal blood vessels immediately. - There are also modern drugs that can reduce bleeding. Some are applied directly to the bleeding area. Here a fibrin glue pad is used to stop blood from oozing out of a dissected liver. - Another effective technique to minimize loss in instances of heavy bleeding is to salvage the patients own blood. Recovery of as much as 50 percent of the blood otherwise lost has

become a reality. This technique also meets the ethical needs of many who absolutely refuse donor transfusions. For instance, some of Jehovahs Witnesses have allowed cell salvage to be used. Cell salvage is a very important technique because when you use cell salvage, the blood lost by the surgeon is not lost for the patient.

10. Can transfusion alternatives work for young children or for people involved in life-threatening emergencies? Answer: Yes. An example shown involved a fouryear-old child born with a serious heart defect who had a series of complex operations without blood transfusions. In one of the busiest trauma centers in the United States that performs hundreds of major operations each year on Jehovahs Witnesses who decline blood, mortality appears to be somewhat decreased.
- To illustrate the impact of properly combined techniques, consider the task faced by the medical team of four-year-old Luana in Modena, Italy. She was born with a serious heart defect. Her team, headed by Professor Marcelletti, chief of cardiovascular surgery, had to perform a series of complex operations. As requested by Luanas parents, the first operation was successfully done without donor blood. Once again, for the second procedure, there were both skilled personnel and the appropriate equipment, including a cell-salvage machine. The meticulous surgery, utilizing electrocautery, took two hours, and Luana lost only 100 milliliters of blood! Her parents were delighted, and the medical team was pleased with the outcome. - In one of the busiest trauma centers in the United States, Professor Cohn, chief of trauma and surgical critical care, notes about patients declining donor blood: We see more than 3,000 patients a year here that are Jehovahs Witnesses, and we do about 250 to 275 major operations on them each year. And what we have seen in our population is no increased length of stay, no increased mortality. In fact, it appears to be somewhat decreased.

11. What is one of the primary ethical principles of good medical care? Answer: Honoring the patients right to accept or reject a certain treatment.
- Transfusion-alternative health care has an ethical benefit. This care honors the patients freedom of choice to accept or reject a certain treatment. One of the primary principles of good medical care is being concerned about what the patient wants. Today one would link that ethical duty not to do harm, to seek the best possible outcome for ones patient, with another duty, which is to respect the autonomy of the patient, to respect the patients own views and decisions. Doctors have virtually an absolute obligation, both legally and ethically, to respect the patients choice. Concerning the advancing legal view generally designated patient rights, Professor Guillod, founder of the Health Law Institute at Neuchtel University comments: I believe the basic element of patients rights is the right of self-determination, that is, the right of any patient to decide what shall be done with his or her own body. Patients have a right to be told that there are alternatives and, more than that there are alternatives, what are the respective risks and benefits expected to be associated with those. - Recognizing patient rights accords with the UNs Universal Declaration of Human Rights. In fact, these legal issues have become so important that in 1997 the Council of Europe formulated the Convention on Human Rights and Biomedicine. Article 5 proclaims: An intervention . . . may only be carried out after the person concerned has given free and informed consent to it.