Date of Award/Publication

12-2013

Document Type

Thesis

Degree Name

M.S. in Advanced Practice Nursing

First Supervisor

Christine Nelson-Tuttle

Abstract

Background and Significance: The Gastroenterology consult service evaluates patients who are admitted to the hospital with gastrointestinal (GI) tract bleeding. Prompt endoscopic evaluation is the mainstay for the diagnosis and treatment of clinically significant GI tract bleeding and occurs in concert with the initiation of supportive measures, including replacement of lost blood, correction of coagulopathy, treatment of hemorrhagic shock, and stimulation of erythropoiesis. There have been several case reports of patients who exsanguinated from acute GI tract bleeding due to refusal of blood or blood products on religious grounds. Management of such patients presents many treatment and ethical challenges. The Jehovah's Witnesses population literally interprets the Bible passages Genesis 9:4, "But flesh with the life thereof, which is the blood thereof, shall ye not eat." and Leviticus 17: 15, "And every soul that eateth that which died of itself, or that which was torn with beasts, whether it be one of your own country, or a stranger, he shall both wash his clothes, and bathe himself in water, and be unclean until the even: then shall he be clean." to mean that they should not ingest blood and thus they do not accept blood or blood products. Nonetheless, there are alternatives, albeit limited, to transfusion of human blood products for patients with acute blood loss secondary to GI tract bleeding. For example, research studies have demonstrated favorable outcomes following the use of recombinant factor Vila to treat anemia and achieve hemostasis (Boffard et. Al, 2005). In addition, as noted by Berend and Levi (2009), there are several unique lessons to be learned from the management of Jehovah's Witnesses with GI tract bleeding, including learning how to seek and utilize alternative treatment options, and understand medical views and beliefs of patients from different cultures and religions. To date, there are no published guidelines that address the management of patients who refuse transfusion of blood or blood products for faith-based reasons. Purpose: To develop an evidence-based treatment protocol for the management of patients who refuse transfusion of blood or blood products for faith-based reasons. Methods: Current evidence was appraised and comparisons were made among the various treatment options for patients who refuse transfusion of blood or blood products for faith-based reasons. Using critical appraisal and synthesis, research studies were scored and beneficial interventions from high-quality studies were incorporated into the evidence-based treatment protocol. Practice recommendations were then organized into a treatment algorithm. Analyses: The algorithm was critiqued by an expert review panel and subsequently revised based on its comments and recommendations. The revised algorithm will be presented to the panel for final approval. Implications: This treatment algorithm will provide clinicians with an evidence-based guide for the medical management of patients who refuse transfusion of blood or blood product.

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