This article was downloaded by: [New York University] On: 17 June 2015, At: 13:16 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Leading Medicine Through “Bloodless” Transplantation a
b
Jessica Varisco & Scott A. Scheinin a
Houston Methodist Hospital
b
Texas Surgical Associates Published online: 06 Jan 2015.
Click for updates To cite this article: Jessica Varisco & Scott A. Scheinin (2015) Leading Medicine Through “Bloodless” Transplantation, The American Journal of Bioethics, 15:1, 75-76, DOI: 10.1080/15265161.2015.975604 To link to this article: http://dx.doi.org/10.1080/15265161.2015.975604
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Research Ethics
Leading Medicine Through “Bloodless” Transplantation
Downloaded by [New York University] at 13:16 17 June 2015
Jessica Varisco, Houston Methodist Hospital Scott A. Scheinin, Texas Surgical Associates Patients have more choices than ever concerning their health care needs. Our patient populations are also getting more and more diverse racially, religiously and ethnically. When you combine the two, health care choices with religious or ethnic concerns, the question arises—how do we, as medical professionals, optimally respect patients’ wishes? Jehovah’s Witnesses have had an answer for many years in an advance directive document that covers endof-life decisions (living will), a medical power of attorney, and first and foremost, a beginning statement concerning their refusal of blood and blood components. A patient’s signature on this document, witnessed by two adults, and stating refusal of whole blood, red blood cells, platelets, and plasma, along with the hospital’s procedure consent form indicating refusal of blood transfusions, allows no deviation, even in the face of life-threatening hemorrhage. Jehovah’s Witnesses are provided those documents and educated on a yearly basis on how to categorically state their position on blood transfusions. There is an expectation among the Jehovah’s Witness community that patients have the responsibility to provide a document (through an advance directive, or AD) that clearly informs the hospital about their wishes regarding blood products and who they want to make decisions for them in the event they become incapacitated. Mr. N did not fulfill his responsibility because these documents were not provided. The hospital has responsibilities to document wishes (Jones, McCullough, and Richman 2007), learned through detailed conversation about transplant, when blood might be necessary, and the impact on transplant outcomes (if any). One chart note stating that the patient refused blood transfusions, which was neither signed nor dated, could be considered an ambiguous document that was not a sufficient AD. As part of our blood conservation program, we have taken several steps to mitigate the chances of this type of case occurring again. A Patient Blood Management program was initiated in October 2012, including hiring a program coordinator who is a Jehovah’s Witness and who is one of the authors of this commentary (JV). She was specifically hired for her current position to address the needs of patients refusing blood transfusions, as well as to adhere to the Society for Thoracic Surgery (STS) recommendations
on blood conservation (Perioperative blood transfusion 2007). Specifically, STS recommends evidence-based guidelines for blood conservation in cardiac surgery (2011 Update 2011; Perioperative blood transfusion 2007). A common misconception is that giving more blood will equate to improved outcomes, but most evidence—summarized in these guidelines—suggests otherwise. These guidelines are based on evidence gathered through treating Jehovah’s Witness patients who have signed releases and legal documents refusing blood transfusions, suggesting that most general surgical procedures can be done with minimal blood loss. Since the publications of these guidelines, many medical organizations, accreditation bodies, and advocacy groups have made blood conservation a focus. The Advancing Transfusion and Cellular Therapies Worldwide (AABB) (Standards 2014), The Joint Commission (2011), the Det Norske Veritas (DNV), the Centers for Disease Control and Prevention (2010), and the American Society of Anesthesiologists (ASA; Committee on Standards and Practice Parameters 2012) are in the process of examining consents for blood transfusions or questioning the validity of giving blood in a safety-conscious era. As a blood management coordinator and a surgical director of a bloodless transplant program, respectively, we contend that the majority of surgical conditions can be treated without the need for banked blood transfusions if meticulous attention is given to preoperative, intraoperative, and postoperative management. We have a robust bloodless transplant program, using several well-developed blood management protocols and measures to reduce blood loss (e.g., correcting preoperative anemia, minimizing perioperative blood loss, keeping withdrawn blood in intraoperative continuity circuits), and our experience reveals excellent outcomes. We have gained extensive knowledge from our operative experience with complex cardiovascular surgeries for Jehovah’s Witnesses. Consequently, our transplant program has experienced meteoric growth in lung transplant volume, exceeding 105 successful bloodless transplants. We have developed a non-blood management consent form to compliment the AD that Jehovah’s Witnesses have for baptized, practicing members. Currently, we have a “non-blood directive” to be used
Address correspondence to Jessica Varisco, Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin, MGJ8-012, Houston, TX, 77030 USA. E-mail: [email protected]
January, Volume 15, Number 1, 2015
ajob 75
Downloaded by [New York University] at 13:16 17 June 2015
The American Journal of Bioethics
when a patient refuses blood transfusions on the main procedure consent form for any surgery. This form includes two options that can be selected: (1) a preference for no blood component transfusions, even at the risk of death or organ failure; or (2) a preference for blood conservation that allows exhausting all options; however, the person can indicate that blood transfusions would be acceptable if he or she is exsanguinating and all other options are exhausted. These would allow a patient to express his or her preferences, and it would allow consideration of options like recycling the patient’s own blood or pretreating patients with hormones to treat anemia prior to surgery. Our goal in creating these documents and developing a robust blood conservation program is to honor wishes of patients in a proactive and deliberate manner by specifically encouraging early discussions with health care professionals, as well as careful documentation of patients’ wishes. & REFERENCES 2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. 2011. Annals of Thoracic Surgery 91:944–982.
76 ajob
Centers for Disease Control and Prevention. 2010. The National Healthcare Safety Network (NHSN) Manual: Biovigilance component. Atlanta GA: CDC. Committee on Standards and Practice Parameters, J. L. Apfelbaum, R. T. Connis, D. G. Nickinovich, et al. 2012. Practice advisory for preanesthesia evaluation: An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 116(3): 522–538. Jones, J. W., L. B. McCullough, and B. W. Richman. 2007. A comprehensive primer of surgical informed consent. Surgical Clinics of North America 67:903–918. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. 2007. Annals of Thoracic Surgery 83:S27–S86. Standards for a patient blood management program developed by the AABB Standard Program Committee. 2014. Available at http://www.aabb.org/pbm/Pages/default.aspx The Joint Commission. 2011. Patient blood management performance measures project. Oakbrook Terrace, IL: The Joint Commission. Available at: http://www.jointcommission.org/patient_ blood_management_performance_measures_project (accessed August 5, 2013).
January, Volume 15, Number 1, 2015
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Leading Medicine Through “Bloodless” Transplantation a
b
Jessica Varisco & Scott A. Scheinin a
Houston Methodist Hospital
b
Texas Surgical Associates Published online: 06 Jan 2015.
Click for updates To cite this article: Jessica Varisco & Scott A. Scheinin (2015) Leading Medicine Through “Bloodless” Transplantation, The American Journal of Bioethics, 15:1, 75-76, DOI: 10.1080/15265161.2015.975604 To link to this article: http://dx.doi.org/10.1080/15265161.2015.975604
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Research Ethics
Leading Medicine Through “Bloodless” Transplantation
Downloaded by [New York University] at 13:16 17 June 2015
Jessica Varisco, Houston Methodist Hospital Scott A. Scheinin, Texas Surgical Associates Patients have more choices than ever concerning their health care needs. Our patient populations are also getting more and more diverse racially, religiously and ethnically. When you combine the two, health care choices with religious or ethnic concerns, the question arises—how do we, as medical professionals, optimally respect patients’ wishes? Jehovah’s Witnesses have had an answer for many years in an advance directive document that covers endof-life decisions (living will), a medical power of attorney, and first and foremost, a beginning statement concerning their refusal of blood and blood components. A patient’s signature on this document, witnessed by two adults, and stating refusal of whole blood, red blood cells, platelets, and plasma, along with the hospital’s procedure consent form indicating refusal of blood transfusions, allows no deviation, even in the face of life-threatening hemorrhage. Jehovah’s Witnesses are provided those documents and educated on a yearly basis on how to categorically state their position on blood transfusions. There is an expectation among the Jehovah’s Witness community that patients have the responsibility to provide a document (through an advance directive, or AD) that clearly informs the hospital about their wishes regarding blood products and who they want to make decisions for them in the event they become incapacitated. Mr. N did not fulfill his responsibility because these documents were not provided. The hospital has responsibilities to document wishes (Jones, McCullough, and Richman 2007), learned through detailed conversation about transplant, when blood might be necessary, and the impact on transplant outcomes (if any). One chart note stating that the patient refused blood transfusions, which was neither signed nor dated, could be considered an ambiguous document that was not a sufficient AD. As part of our blood conservation program, we have taken several steps to mitigate the chances of this type of case occurring again. A Patient Blood Management program was initiated in October 2012, including hiring a program coordinator who is a Jehovah’s Witness and who is one of the authors of this commentary (JV). She was specifically hired for her current position to address the needs of patients refusing blood transfusions, as well as to adhere to the Society for Thoracic Surgery (STS) recommendations
on blood conservation (Perioperative blood transfusion 2007). Specifically, STS recommends evidence-based guidelines for blood conservation in cardiac surgery (2011 Update 2011; Perioperative blood transfusion 2007). A common misconception is that giving more blood will equate to improved outcomes, but most evidence—summarized in these guidelines—suggests otherwise. These guidelines are based on evidence gathered through treating Jehovah’s Witness patients who have signed releases and legal documents refusing blood transfusions, suggesting that most general surgical procedures can be done with minimal blood loss. Since the publications of these guidelines, many medical organizations, accreditation bodies, and advocacy groups have made blood conservation a focus. The Advancing Transfusion and Cellular Therapies Worldwide (AABB) (Standards 2014), The Joint Commission (2011), the Det Norske Veritas (DNV), the Centers for Disease Control and Prevention (2010), and the American Society of Anesthesiologists (ASA; Committee on Standards and Practice Parameters 2012) are in the process of examining consents for blood transfusions or questioning the validity of giving blood in a safety-conscious era. As a blood management coordinator and a surgical director of a bloodless transplant program, respectively, we contend that the majority of surgical conditions can be treated without the need for banked blood transfusions if meticulous attention is given to preoperative, intraoperative, and postoperative management. We have a robust bloodless transplant program, using several well-developed blood management protocols and measures to reduce blood loss (e.g., correcting preoperative anemia, minimizing perioperative blood loss, keeping withdrawn blood in intraoperative continuity circuits), and our experience reveals excellent outcomes. We have gained extensive knowledge from our operative experience with complex cardiovascular surgeries for Jehovah’s Witnesses. Consequently, our transplant program has experienced meteoric growth in lung transplant volume, exceeding 105 successful bloodless transplants. We have developed a non-blood management consent form to compliment the AD that Jehovah’s Witnesses have for baptized, practicing members. Currently, we have a “non-blood directive” to be used
Address correspondence to Jessica Varisco, Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin, MGJ8-012, Houston, TX, 77030 USA. E-mail: [email protected]
January, Volume 15, Number 1, 2015
ajob 75
Downloaded by [New York University] at 13:16 17 June 2015
The American Journal of Bioethics
when a patient refuses blood transfusions on the main procedure consent form for any surgery. This form includes two options that can be selected: (1) a preference for no blood component transfusions, even at the risk of death or organ failure; or (2) a preference for blood conservation that allows exhausting all options; however, the person can indicate that blood transfusions would be acceptable if he or she is exsanguinating and all other options are exhausted. These would allow a patient to express his or her preferences, and it would allow consideration of options like recycling the patient’s own blood or pretreating patients with hormones to treat anemia prior to surgery. Our goal in creating these documents and developing a robust blood conservation program is to honor wishes of patients in a proactive and deliberate manner by specifically encouraging early discussions with health care professionals, as well as careful documentation of patients’ wishes. & REFERENCES 2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. 2011. Annals of Thoracic Surgery 91:944–982.
76 ajob
Centers for Disease Control and Prevention. 2010. The National Healthcare Safety Network (NHSN) Manual: Biovigilance component. Atlanta GA: CDC. Committee on Standards and Practice Parameters, J. L. Apfelbaum, R. T. Connis, D. G. Nickinovich, et al. 2012. Practice advisory for preanesthesia evaluation: An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 116(3): 522–538. Jones, J. W., L. B. McCullough, and B. W. Richman. 2007. A comprehensive primer of surgical informed consent. Surgical Clinics of North America 67:903–918. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. 2007. Annals of Thoracic Surgery 83:S27–S86. Standards for a patient blood management program developed by the AABB Standard Program Committee. 2014. Available at http://www.aabb.org/pbm/Pages/default.aspx The Joint Commission. 2011. Patient blood management performance measures project. Oakbrook Terrace, IL: The Joint Commission. Available at: http://www.jointcommission.org/patient_ blood_management_performance_measures_project (accessed August 5, 2013).
January, Volume 15, Number 1, 2015
