Not a drop to spare - Jehovah's witnesses in the ICU

Todd Fraser on 29-01-2013

I was sent details of an interesting case that captured my attention recently.

It was a 70 year old man who was a life-long Jehovah's Witness, who had clearly and legally documented his decisions on the use of blood products, who presented with a bleeding duodenal ulcer.

After an attempt to stop the bleeding via endoscopy, he was rapidly converted to a surgical oversew. He returned to the ICU with a haemoglobin of 32g/L. He was on a ventilator, wide awake, on high FiO2s (saturating at 100%) for a week, before his lactate began to rise. Despite heavy sedation, he eventually died.

This is not an unfamiliar story to clinicians in ICU. There are numerous medical issues, and the medicolegal and ethical issues it throws up are just as important.

Clinically, how do you deal with this? How do we maximise oxgyen delivery and minimise waste? At what point does the risks of prolonged ventilation outweigh its benefits?

Ethicolegally, how do you deal with this issue?

Let me know your thoughts and questions below.

3 Comments

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Gordon West from United Kingdom wrote 01-29-2013 04:07:57 pm
I guess the basics are that you minimise blood loss (from procedures, blood tests etc), high dose PPIs, maximise nutrition, EPO (unless you're an olympic cyclist), iron infusions, B12, folate, hope for the best.

The question of whether or not you sedate him +/- paralysis to conserve oxygen is complex. Doing so commits him to the risk of VAP and other complications. The high FiO2 will achieve absolutely nothing - once he's saturating at 100%, there is no advantage, and possibly harm, associated with higher inspired pressures of O2.

When do you extubate him? I'd be tempted to accept normal markers - if he can vent adequately, had a normal lactate, minimal inotropic support, good airway control etc. You can always put it back...

Hella from Denmark wrote 02-23-2013 11:55:42 am
You can't sedate this guy for ever. I think if his lactate is normal and sats are acceptable you should extubate him. If his sats are alright, raising his PaO2 is not going to make any difference.

Gemma from Canada wrote 02-25-2013 10:54:06 am
I think the clinical issues are pretty straight forward.

Its the ethical issues that create the difficulty. Its not uncommon to feel some frustration with these patients I think - there is an accepted medical therapy that could improve the situation, but its being refused. If you extubate, do you reintubate if the patient fails? If the Hb remains at 32, isn't it a futile exercise?