To transfuse or not to transfuse? Jehovah's Witnesses and postoperative hemorrhage in pediatric otolaryngology.

Objectives: Discuss the ethical issues in the management of postoperative hemorrhage in pediatric patients whose parents are Jehovah's Witnesses (JW) and 2) Describe a framework for shared decision making in this population.

Methods: A recall review of pediatric otolaryngology patients with parents of the JW faith and postoperative hemorrhage was performed over a year long period at a single institution. The literature on transfusions for JW minors was reviewed.

Results: Two patients were identified. The first patient had a severe post-tonsillectomy hemorrhage requiring multiple emergency operative interventions. The child developed a hemoglobin of 5.2 g/dl and received an emergent transfusion against parents' wishes. The child subsequently did not require further intervention. The second patient hemorrhaged after a supraglottoplasty and was administered erythropoietin and iron infusion but did not require transfusion (hemoglobin nadir 7.9 g/dl). In both cases hematology was consulted, and extensive discussion with the families and the JW Hospital Liaison Committee occurred.

Conclusions: The risks of hemorrhage should be discussed with JW parents of patients undergoing even routine otolaryngologic surgery. In these cases, early shared decision making with family, the JW Hospital Liaison committee, and hematology was pursued regarding mutually acceptable interventions. Aggressive non-transfusion based resuscitation was carried out to minimize the likelihood of transfusion. In the first case, danger to the patient's life eventually necessitated transfusion in accordance with the patient's best interest and previous case law. A defined framework involving all stake-holders, including Pastoral Care, in the event of postoperative hemorrhage is critical.