Practicing bloodless medicine
Any hospital can practice bloodless medicine, as this area of medicine does not always need to involve advanced techniques, expensive equipment, or esoteric methods of patient care. In many cases, optimization of bloodless medicine patient care can be managed with a careful review of current medical practices. Laboratory testing is a great example of this: we order labs on most hospitalized adult patients each day as a routine, but this practice has been associated with increased needs for transfusion in some patient populations.1 Hospital-acquired anemia, which can occur as a consequence of daily routine blood draws, is associated with increases in-hospital mortality and resource utilization.2 In the bloodless medicine subset of patients, daily phlebotomy may cause excessive and unnecessary blood loss which may be harmful.
Surviving without transfusion
It is important to remember that the bloodless medicine patient can remain alive without receiving blood. Although it may seem impossible to many of us, patients do survive without receiving blood transfusions for acute blood loss anemia with hemoglobin concentrations as low as 3-4 mg/dL. We learn early in our training that acutely anemic patients should receive blood transfusions, but we do not learn how to manage patients who cannot receive such transfusions.
Simple, effective interventions
When blood transfusion is unable to be performed on a patient due to medical or religious reasons, members of the medical team may react with frustration or anger. In some cases, the focus on the perceived need for transfusion may distract the medical team from ordering other consultations or procedures that could be performed to control active bleeding. There are many simple interventions that can be implemented as soon as the patient arrives at the hospital, to reduce the indications for blood transfusion and optimize care of the bloodless medicine patient.
Typical vacutainers can hold anywhere from 2-10 milliliters of blood. Phlebotomists often draw a “rainbow” of 7 vacutainers in the Emergency Department in anticipation of tests being ordered by a physician, and this can result in an acute blood loss of 20 or more milliliters from one phlebotomy draw. In one study of transfusion practices in ICU patients, phlebotomy draws resulted in blood loss exceeding 70 milliliters per day.3 For the bloodless medicine population, utilization of a careful phlebotomy technique with attention to the number of vacutainers used can result in reduced unnecessary blood loss. Instead of directing a phlebotomist to draw a “rainbow” of tubes, we can consider asking the phlebotomy staff to hold off on drawing blood until a physician has evaluated the patient (a “bloodless medicine” wristband, bedside sign, or other identification method can be created for the patient at triage in order to alert hospital staff of the patient’s status). Then, based on the physician’s evaluation, a focused phlebotomy attempt can be performed. In addition, the choice of vacutainer can affect the phlebotomy amount. Pediatric microtainers, which hold 200-600 microliters of blood, can be substituted for typical vacutainers in the bloodless medicine population, additionally reducing unnecessary blood loss. Point-of-care testing, which requires significantly reduced quantities of blood for analysis compared with traditional phlebotomy, is another option for laboratory testing in the Emergency Department.
We suggest that Emergency Departments consider implementation of both focused phlebotomy techniques and use of pediatric microtainer tubes or point-of-care testing, in the bloodless medicine population.
Along with the volume of blood drawn, the frequency of blood draw attempts can also contribute to iatrogenic acute blood loss. Computerized entry sets for laboratory orders often default to a daily frequency for blood draws, but daily labs are not often needed in every patient. For the bloodless medicine population, a simple change in the frequency of blood draws from every day to every other day can result in a reduction in blood loss that can be potentially life-saving. We must think about why we are ordering labs, and not just what we are ordering. For many bloodless medicine patients, especially those who are admitted due to complications of acute anemia, checking a daily complete blood count will not change the treatment plan since transfusion is not an option. Thus, it is completely reasonable to check labs every 2-3 days, or even less frequently, in this patient population.
Predicting hemoglobin rise
Human erythrocytes take approximately one week to mature.4 For short-term monitoring in the bloodless medicine patient who is already being treated with erythropoietin and/or other hematinic agents, hemoglobin and hematocrit concentrations are of low utility due to the known length of time required for red blood cell maturation. Other laboratory parameters, such as the automated reticulocyte count, can be useful as adjunctive assays for quantifying a patient’s erythropoietic response. Additional reticulocyte assays, including the reticulated hemoglobin, absolute reticulocyte count, and immature reticulocyte percentage, may also be helpful when attempting to quantify the degree of erythropoiesis in a bloodless medicine patient.
For example, even though a patient’s hemoglobin may remain stable over a period of days, serial increases in the above reticulocyte assays during this time indicates that erythropoiesis is actively occurring and that an elevation in hemoglobin concentration is likely to occur in upcoming days (assuming that any acute bleeding has ceased). This information is reassuring to both the physician and the patient, can be used for discharge planning purposes, and may even translate into reduced lengths of hospital stay for bloodless medicine patients.
Respecting patient choices
While the judicious use of laboratory monitoring is a critical concept in the management of the hospitalized bloodless medicine patient population, the importance of interpersonal interactions with bloodless medicine patients is infrequently discussed but also requires attention. Bloodless medicine patients, and specifically the Jehovah’s Witness population, are an educated and knowledgeable group of patients. Jehovah’s Witnesses are keenly aware of the risks of not accepting blood products, including the risk of death. As physicians, our beliefs regarding blood transfusion may differ from those of the Jehovah’s Witness population; however, each of us is entitled to our own beliefs, and one belief is not necessary superior to another. As physicians, we must accept the beliefs of patients, even when they differ from ours, and treat the patient according to their beliefs, not ours. It is the patient who is receiving the treatment; therefore it is the patient’s informed choices that have ethical and legal control.
Withholding treatment not an option
All too frequently, patients who are transferred to my institution for bloodless medicine services will tell me that another doctor told them they “would die” if they did not receive blood or that there is “nothing else that can be done” for the patient because they were not able to receive blood. Some patients have left the original hospital against medical advice after being pressured to receive a blood transfusion with no alternative methods of treatment offered; this unfortunately resulted in further delays in their medical care.
As has already been discussed, there is always something that can be done; any hospital, regardless of size or academic reputation, has resources available to treat the bloodless medicine population. Interventions as simple as acknowledging a patient’s religious beliefs by placing a “bloodless medicine” wristband on the patient and a similar sign on the door to reduce unnecessary phlebotomy attempts, are not only beneficial in the overall treatment of bloodless medicine patients; these interventions can also subtly alert the patients that we are working with them, not against them, for their medical care.
Treat or refer immediately
The concept of “working with the patient” is crucial in the treatment of bloodless medicine patients. If a physician attempts to convince a Jehovah’s Witness patient to accept blood either actively (by repeatedly telling the patient that they need a blood transfusion) or passively (by telling the patient “you may die” or “there is nothing else that can be done”), the patient’s appropriately negative response may be recorded in the medical record as an example of noncompliant behavior. The term “noncompliant” has a negative connotation in the medical field and may lead to conscious or implicit bias and disparities in the quality of patient care.
For a patient, the description of noncompliance may, in turn, lead to impairments in the relationship between the patient and the other members of the medical team, further breakdowns in communication, and marginalization of the patient and his/her needs.
Instead of assigning the description of noncompliance to patients who are unable to receive blood transfusion due to religious reasons, it is more beneficial to acknowledge the patient’s difference in beliefs and implement a treatment plan that takes the religious beliefs into consideration. The ultimate treatment plan may not be the easiest or the fastest (i.e., it may involve the use of erythropoietin, hematinic agents, and hyperbaric oxygen therapy instead of a blood transfusion), but it will share the same goals of care while respecting the patient’s religious autonomy.
If a physician, for whatever reason, is not able to care for a patient without the use of blood transfusion, the patient should be referred or transferred immediately to a physician or hospital willing and able to provide appropriate care. Failure to act promptly may result in harm to the patient.
Simple interventions, rich rewards
We know that severely anemic patients can survive without receiving blood transfusions; simple recognition and acceptance of this fact allows us, as treating physicians, to consider other currently available options to minimize blood loss and augment erythropoiesis. Basic interventions, such as limiting unnecessary blood draws and understanding which laboratory assays are most relevant for a particular patient population, can greatly enhance our ability to care for those for whom blood transfusion is not an option.
These same techniques can also be applied to our daily medical practice for all patients, and can result in reductions in hospital-acquired anemia, avoidance of transfusion-related complications, and optimized outcomes for all of our patients.
The practice of bloodless medicine does not have to be a difficult or complex process. It does require a willingness on the part of the doctor to respect the patient’s choices, review current medical practices, and creatively find new plans for care. Clinicians who do these things earn their patients’ gratitude and deep respect.