Bloodless Doesn’t Mean Careless: Lessons from Patients Who Say No

When a patient refuses a blood transfusion, many clinicians feel backed into a corner.

Sometimes, that refusal stems from deeply held religious beliefs—most notably among Jehovah’s Witnesses, who typically decline whole blood and its primary components. But here's the truth: refusing transfusion doesn’t mean refusing care. It means we need to be better stewards of everything else we have.

🔄 From “No” to “Now What?”

Too often, the conversation stops at “They won’t accept blood.” But clinically, the more urgent question is: what can we offer instead?

Fortunately, there’s a growing arsenal of strategies—many pioneered in response to transfusion refusal—that improve outcomes across the board. And the data backs that up.

💉 Bloodless Cardiac Surgery: The Data

Consider cardiac surgery, one of the most transfusion-intensive fields in modern medicine. In a 10-year retrospective study of 91 Jehovah’s Witness patients undergoing cardiac procedures at a single institution, in-hospital mortality was just 5.5%, with outcomes for isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) falling within the 95% confidence intervals of Society of Thoracic Surgeons (STS) risk model predictions. Major complications—including reoperation, sepsis, stroke, and dialysis—remained low, and results were consistent across both elective and urgent surgeries.¹

These findings are echoed in a 2024 meta-analysis of 10 studies involving 780 Jehovah’s Witnesses and 1,182 non-Witness controls undergoing cardiac surgery. Despite 86% of non-Witness patients receiving at least one transfusion, there was no significant difference in perioperative mortality (OR 0.91; 95% CI, 0.55–1.52; p = 0.72). Jehovah’s Witnesses had less total blood loss (p = 0.001), and both pre- and postoperative hemoglobin levels were significantly higher.²

In short: bloodless cardiac surgery is not only possible—it’s safe, when care is proactive and deliberate.

🧬 Blood Products and the Nuance of Refusal

To care well for patients who decline transfusion, we need more than clinical tools—we need clarity.

Here's the breakdown:

Whole Blood

Contains all components: red cells, white cells, plasma, and platelets. Jehovah’s Witnesses universally reject transfusion of whole blood.

Primary Components

Directly separated from whole blood. These are typically not accepted.

• Red blood cells

• Plasma

• Platelets

• White blood cells

  
  

Secondary Components (Blood Derivatives)

Created by further processing or fractionating blood components. Some Jehovah’s Witnesses accept these products, depending on individual beliefs and local congregation guidance.

• Albumin

• Immunoglobulins

• Coagulation factor concentrates

• Cryoprecipitate

  
  
  
  

Autologous vs. Allogeneic Transfusion

• Allogeneic: from a donor—generally not accepted.

• Autologous: from the patient’s own circulation—may be accepted if done through a closed-loop system (e.g., cell salvage).

  
  

This is why personalized planning and transparent communication are essential. Always clarify what the patient will or won’t accept—because individual preferences can vary dramatically within the community.

🛠️ What It Takes to Do Bloodless Medicine Well

The best outcomes don’t come from avoiding transfusion—they come from deliberate patient blood management (PBM). Many of the tools that support JW patients improve care systemwide.

Preoperative Optimization

• Iron, B12, and folate supplementation

• Erythropoiesis-stimulating agents

• Minimizing iatrogenic blood loss

  
  

Intraoperative Precision

• TXA and other antifibrinolytics

• Meticulous surgical technique

• Cell salvage (when acceptable)

  
  

Postoperative Support

• Tolerance of lower Hgb thresholds

• Oxygen and volume support

• Strategies to support marrow recovery

  
  

💡 What This Teaches Us

Caring for patients who decline transfusion isn’t a constraint—it’s a clinical and ethical opportunity.

It pushes us to:

• Communicate better

• Plan ahead

• Treat each patient as a partner in care

  
  

And above all, it reminds us that the safest blood is the unit we never have to give.

📚 References

1. Jassar AS, Makar M, Pullins E, et al. Cardiac Surgery in Jehovah’s Witness Patients: Ten-Year Experience. Ann Thorac Surg. 2012;93(1):19–25. doi:10.1016/j.athoracsur.2011.07.076

2. Gemelli M, Italiano EG, Geatti V, et al. Optimizing Safety and Success: The Advantages of Bloodless Cardiac Surgery. A Systematic Review and Meta-Analysis of Outcomes in Jehovah’s Witnesses. Curr Probl Cardiol. 2024;49(1, Part B):102078. doi:10.1016/j.cpcardiol.2023.102078