A Jehovah's Witness With Placenta Accreta Asks for Reassurance
34-year-old G2P1 at 37 weeks with placenta previa and suspected accreta on MRI. She is one of Jehovah's Witnesses and has a signed, witnessed advance directive refusing red cells, platelets, plasma, and cryoprecipitate under all circumstances, including death. She accepts albumin, crystalloid, tranexamic acid, erythropoietin, iron, and cell salvage with a continuously connected circuit. Preoperative Hb 10.8 g/dL, platelets 210, INR 1.0, fibrinogen 380 mg/dL. Elective cesarean hysterectomy is planned. Just before transfer to the OR she asks, 'If I bleed and pass out, you will do what is needed, right?'
1. How do you answer her question, and what has to be in place before she enters the OR?
Read the worked answer
Answer her honestly. 'What is needed, in your definition, is exactly what we will do - and that does not include blood products. If you are unconscious, we follow this document.' Vagueness here is not kindness; it is a setup for a conflict in the middle of an emergency, and it damages trust if she later learns the plan was ambiguous.
Before the OR
- Reconfirm the directive point by point in her own words: which specific products and fractions are refused, whether she accepts cell salvage with circuit continuity, recombinant factor VIIa, prothrombin complex, albumin, and whether she has any conditional clauses (some accept fractions, some do not). Write it down verbatim.
- Verify capacity and voluntariness - no coercion, no acute distress, and document it. A competent adult refusal, made contemporaneously, remains valid when capacity is later lost.
- Ethics consultation and legal review in advance, not during hemorrhage, plus notification of the blood bank and hospital leadership.
- Assemble the bloodless protocol: preoperative iron/EPO optimization, tranexamic acid 1 g at incision and repeat, cell salvage set up and running before incision, prophylactic uterotonics, interventional radiology on standby for aortic balloon or embolization, surgeon committed to early hysterectomy rather than prolonged uterine-sparing attempts, deliberate normothermia, and point-of-care coagulation testing to guide non-blood factor replacement.
- Brief the whole team including the plan for moral distress and who will speak for the directive.
2. Intraoperatively there is 3 L of blood loss; Hb is 4 g/dL, MAP 45 mmHg, and she is intubated and unresponsive. What do you do?
Read the worked answer
Treat the physiology with the tools she authorized, and do not transfuse. Unconsciousness does not create an exception - the emergency exception exists to provide treatment a patient would want, and a valid, documented, contemporaneous refusal tells you the opposite.
Immediate actions
- Definitive surgical hemorrhage control: tell the surgeon to move to hysterectomy now; this is the intervention with the largest effect.
- Accepted resuscitation: balanced crystalloid and albumin, additional tranexamic acid, fibrinogen concentrate or cryoprecipitate-free factor replacement only if her directive permits specific fractions (this must already be settled), cell salvage return with a connected circuit, vasopressors to defend perfusion pressure, active warming, calcium replacement, correction of acidosis.
- Escalate mechanically: activate interventional radiology, consider resuscitative endovascular balloon occlusion of the aorta, and if the directive allows, recombinant factor VIIa.
- Reassess the goal: with Hb 4, survival may be impossible under these constraints. Shift to comfort-focused and family-supported care if hemorrhage cannot be controlled, and say so out loud to the team rather than drifting into a futile, unspoken position.
- Document everything in real time, including that blood products were withheld per the patient's directive.
3. A colleague pulls you aside and proposes giving two units of red cells and documenting it as an emergency necessity. How do you respond, and what do you do next?
Read the worked answer
Refuse, clearly and immediately. Transfusing against a valid, specific, documented refusal is battery - it exposes the clinician and the institution to liability, professional discipline, and, more importantly, it overrides a competent person's most fundamental values. The fact that death might follow is precisely what she considered and accepted.
What to say. State the legal and ethical position without moralizing, name the directive in the chart, and make clear you will not sign the order or administer the product. If the colleague persists, escalate in real time to the attending of record, the ethics committee, and risk management - this is a situation where a pause of ten minutes matters.
Constructive alternative. Redirect the energy to what is permitted and effective: definitive surgical control, tranexamic acid, cell salvage, mechanical adjuncts. Confirm that the patient's own prior statements and the witnessed directive are in the chart.
Protect the team. Debrief after the case; moral distress is a genuine occupational harm. If a clinician cannot in conscience provide care honoring the directive, the correct move is an explicit, documented handoff to a willing colleague - never covert treatment and never abandonment.