Approaches to a Patient With Anemia Who Is Refusing a Blood Transfusion

A 33-year-old woman presents with symptomatic anemia. She reports a long history of abnormal uterine bleeding and is currently menstruating. On admission, her blood pressure is 105/90 mm Hg, and her heart rate is 113 beats per minute. She reports lightheadedness when standing and dyspnea on exertion. Her hemoglobin (Hb) is 4.9 g per dL (49.0 g per L), with a mean corpuscular volume of 61.0 μm³ (61.0 fL), which indicates severe iron deficiency. I recommend transfusion of two units of packed red blood cells; however, she tells me that she and her husband are practicing Jehovah's Witnesses, and she provides a blood-refusal advance directive card.

What is my role as a physician when a patient refuses a potentially lifesaving blood transfusion? Are there any circumstances in which physicians have an ethical responsibility to prioritize lifesaving treatment over the requests of a patient or their family members?

Critically anemic patients who refuse blood transfusions have an inverse relationship between Hb levels and morbidity and mortality, particularly for Hb levels less than 5.0 g per dL (50.0 g per L).^1–3 For every 1 g per dL (10.0 g per L) drop in Hb below 8 g per dL (80.0 g per L), the risk of death increases 2.5-fold.⁴ Blood transfusions are a foundational component of treating severe anemia and are considered a lifesaving therapy.⁵ This makes caring for patients with severe anemia who refuse blood transfusions challenging. Physicians are bound by the four principles of medical ethics: autonomy, beneficence, nonmaleficence, and justice.⁶ To honor a patient's autonomous decision, a physician may face violating the other principles they have sworn to uphold. Respecting a patient's autonomy generally outweighs the other principles when treatment is refused.⁷ Importantly, declining a specific treatment modality does not imply refusal of all medical care and should not require patients to sign documentation of declining treatment against medical advice.⁵

Patients may refuse blood transfusions for several reasons, including fear of contracting a bloodborne pathogen, previous adverse transfusion reactions, financial constraints, or the desire to discontinue life-prolonging therapies in a terminal illness; one well-known scenario is refusal on religious grounds, particularly by Jehovah's Witnesses.

Ethical and moral convictions leading patients to avoid blood products have stimulated the development of medical strategies, appropriately termed “bloodless medicine and surgery.” Recommendations have been created collaboratively by organizations, physicians, and patients that are designed to optimize medical outcomes without the use of blood transfusion therapies.⁵

Some physicians may disagree or are significantly uncomfortable with a patient's choice to refuse blood transfusions. These situations place a heavy emotional toll on health care professionals, especially when the patient risks dying from a “preventable” medical condition or complications of untreated anemia. In these circumstances, it is reasonable for a physician in a nonemergent setting to refer the patient to another health care professional who is aware of the patient's medical preferences and who is willing to assume health care.

The approach to caring for patients refusing blood products can be complex. Individualized, patient-centered interviewing and shared decision-making are essential. First and foremost, the patient must exhibit the capacity to refuse any lifesaving treatment.⁸ To possess capacity, the patient must be able to understand the information being provided to them at a fundamental level, appreciate the gravity of the situation and the risks and benefits of proposed treatment options and their likely outcomes, evaluate these options through a rational thought process, and clearly and consistently communicate their choice after demonstrating the ability to meet these criteria.⁹ Autonomous refusal of treatment must be respected, despite the consequences, if a patient is determined to have capacity.⁷