Policy 1

Accept the limitation that allogenic blood cannot be used

Policy 2

Use alternatives to allogenic blood whenever possible and appropriate

• Jehovah's Witnesses refuse all allogenic blood products and any autologous blood that has been separated from the body. These proibitions do not prevent most Witnesses from accepting the use of cardiopulmonary bypass, dialysis, intraoperative blood salvage, and reinfusion. Although the casual observer may not discern a difference between these interventions and autologous blood that has been separated from the body, Jehovah's Witnesses distinguish acceptable therapy from unacceptable according to whether the diverted blood is still part of the circulatory system. In dialysis and cardiopulmonary bypass, blood remains part of the circulation. Autotransfusion devices can meet this test by dedicating an intravenous line from the collection device to the patient to mantain a closed circuit. Hemodiluition can be similary modified.
• Jehovah's Witnesses readily accept most drugs, such iron dextran, aprotinin, desmopressin, and syntetic "blood substitutes", because these agents contain no human blood products. Hemoglobin-based blood substitutes are unacceptable to Jehovah's Witnesses if they contain human or animal blood.
• As a matter of conscience, Jehovah's Witnesses may accept some products that contain blood products, such a immune globulin. Epoetin alfa, wich contains a small amount of human albumin, is acceptable to most Jehovah's Witnesses. Albumin will likely be refused coscientiously when used as a volume expander, but the amount contained in Epoetin alfa is small and therefore generally acceptable.

Policy 3

Discuss consequences with the patient, including the potential for life-threatening hemorrage and possible death if not transfused

Policy 4

If unable or unwilling to treat a Jehovah's Witnesses patient. stabilize and transfer the patient to a sympatetic institution, such a Center for Bloodless Surgery

• Each surgeon must make a personal decision regarding the acceptability of the proibition against transfusion. If it is not acceptable, then Jehovah's Witnesses should be referred to physicians who are sympathetic to their beliefs.
• The doctrine "If you can't transfuse, transfer" has helped save many lives. Time should not be wasted in misguided attempts to convince the Jehovah's Witnesses patient by argument and logic or in waiting for the situation to worsen in hoes the patient will agree to transfusion at the operating room door. Such actions may rob actively bleeding patients of a chance for survival.

Policy 5

Contact the local Jehovah's Witnesses liaison committee for information and help

• The Jehovah's Witnesses church has established local liaison committees consisting of well-informed church members prepared to act as a link between the physician and the patient. committee members can provide the phisician with a clear understainding of Jehovah's Witnesses' position and use of alternatives, and can help locate and arrange assistance from or referral to a Center for Bloodless Surgery.

Policy 6

Seek legal assistance when dealing with an unconscious or incompetent adult; look for an advance directive

• In an emergency or when the patient is unconscious, the traditional approach is to stabilize the patient first, wich may include the use of blood transfusion, and to seek consent later. 
• Most Jehovah's Witnesses carry a card proclaiming them as such and describing ther refusal of blood and blood products. One must consider this card to be valid and binding because it carries the weight of an advance directive. In Malette v Shulman, the Ontario Court of Appeals estabilished this precedent by awarding damages to a Jehovah's Witnesses who was transfused even thoug she had such a card in her possession. When in doubt, the hospital's attorney should be consulted.