Caring for minors who are members of the Jehovah’s Witness (JW) faith requires understanding the basic premises of the JW faith; thoroughly reviewing the patient’s baseline medical condition in view of the proposed surgery; honestly and respectfully communicating with the family to formulate a collaborative plan; and using (when necessary) the legal doctrine of parens patriae.

It is sometimes difficult for anesthesia providers to understand that refusing to consent to the administration of blood products for their minor children is an entirely logical extension of the faith of JW parents. JW members believe that, when the end of life on earth has come, a chosen few will be resurrected for a life on earth that will be both physical and eternal. When JW members refuse blood products, they are living according to their faith, choosing eternal life over earthly life. Therefore, they regard refusal of blood products for their children as a positive act, not as neglect or martyrdom.

Preoperative optimization of the patient’s medical status is of paramount importance when caring for minor patients who are JW members, especially when the patient has a baseline anemia. The source of the anemia, whether from a medical condition or from a previous surgery, should be elucidated. The patient may require a course of erythropoietin and iron supplementation. It is also important that conditions such as asthma and seizure disorders be under good surveillance and appropriately managed. The anesthesia provider should be willing to request delay of the case (if not emergent) and to seek the advice of consultants, if necessary.

The nature of the surgical case and the modalities available to minimize blood loss should be firmly established. Is the surgery urgent or emergent? Is the procedure one that typically has considerable blood loss? How well will the child tolerate anemia? What is the best estimate of the lowest “permissible” hemoglobin level in the intraoperative and perioperative period? Answering these questions generally requires collaborative discussion with the surgeon. Similarly, several blood loss-sparing modalities can be used in minor and adult patients who are JW members, and there should
be a consensus between the surgical and anesthesia staff about their use as well. These modalities include controlled hypotension, tourniquet use, acute normovolemic hemodilution, and cell-salvage techniques.

The specific beliefs of the patient’s parents must be established to develop a collaborative plan of care. To review, some JW members refuse primary blood components, including red blood cells, white blood cells, plasma and platelets, but will accept albumin, fibrin, clotting factors, acute normovolemic hemodilution, and cell salvage. All pertinent members of the perioperative care team should meet with the patient and the patient’s parents. It is important that the anesthesiologists clearly communicate the plan to minimize the possibility of transfusion to the parents and to assure them that their beliefs are understood and respected. The anesthesiologist should ask for help from the ethics committee, hospital administrative staff, or JW liaison office if he or she feels uncomfortable in this or if there is significant disagreement or discord between the parents. Many pediatric centers also have an informational form that the parents must read and sign, acknowledging the parents’ religious beliefs and respectfully promising to do everything medically possible to avoid blood-product administration. The form usually states the legal obligation of the health-care providers to avoid jeopardizing the life of the child by not giving blood products when they are deemed absolutely necessary and reiterates that, regardless of the parental consent status, moral responsibility and legal precedence requires transfusion if it is necessary to prevent harm or death.